Evidence Report/Technology Assessment 

Number 9 

Closing the Quality Gap: 

A Critical Analysis of Quality Improvement Strategies 

Volume 6—Prevention of Healthcare-Associated Infections 

Prepared for: 

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

540 Gaither Road 

Rockville, MD 20850 

www.ahrq.gov 

Contract No. 290-02-0017 

Prepared by: 

Stanford University-UCSF Evidence-based Practice Center, Stanford, CA 

Series Editors 

Kaveh G. Shojania, M.D., University of California, San Francisco 

Kathryn M. McDonald, M.M., Stanford University 

Robert M. Wachter, M.D., University of California, San Francisco 

Douglas K. Owens, M.D., M.S., VA Palo Alto Health Care System, Palo Alto, California; 

Stanford University

Investigators 

Sumant R. Ranji, M.D. 

Kanaka Shetty, M.D. 

Keith A. Posley, M.D. 

Robyn Lewis, M.A. 

Vandana Sundaram, M.P.H. 

Cristina M. Galvin, M.S., M.A. 

Lisa G. Winston, M.D. 

AHRQ Publication No. 04(07)-0051-6 

January 2007
This report is based on research conducted by the Stanford-UCSF Evidence-based Practice Center 

(EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD 

(Contract No. 290-02-0017). The findings and conclusions in this document are those of the 

author(s), who are responsible for its contents, and do not necessarily represent the views of 

AHRQ. No statement in this report should be construed as an official position of AHRQ or of the 

U.S. Department of Health and Human Services. 

The information in this report is intended to help clinicians, employers, policymakers, and others 

make informed decisions about the provision of health care services. This report is intended as a 

reference and not as a substitute for clinical judgment. 

This report may be used, in whole or in part, as the basis for development of clinical practice 

guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage 

policies. AHRQ or U.S. Department of Health and Human Services endorsement of such 

derivative products may not be stated or implied. 
ii 

This document is in the public domain and may be used and reprinted without permission except 

those copyrighted materials noted for which further reproduction is prohibited without the 

specific permission of copyright holders. 

Suggested Citation: 

Ranji SR, Shetty K, Posley KA, Lewis R, Sundaram V, Galvin CM, Winston LG. Prevention of 

Healthcare-Associated Infections. Vol 6 of: Shojania KG, McDonald KM, Wachter RM, Owens 

DK, editors. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. 

Technical Review 9 (Prepared by the Stanford University-UCSF Evidence-based Practice Center 

under Contract No. 290-02-0017). AHRQ Publication No. 04(07)-0051-6. Rockville, MD: 

Agency for Healthcare Research and Quality. January 2007.

None of the investigators has any affiliations or financial 

involvement that conflicts with the material presented in 

this report. 
iii

Preface 

 The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-Based 

Practice Centers (EPCs), sponsors the development of evidence reports and technology 

assessments to assist public- and private-sector organizations in their efforts to improve the 

quality of health care in the United States. The reports and assessments provide organizations 

with comprehensive, science-based information on common, costly medical conditions and new 

health care technologies. The EPCs systematically review the relevant scientific literature on 

topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to 

developing their reports and assessments. 

 To bring the broadest range of experts into the development of evidence reports and health 

technology assessments, AHRQ encourages the EPCs to form partnerships and enter into 

collaborations with other medical and research organizations. The EPCs work with these partner 

organizations to ensure that the evidence reports and technology assessments they produce will 

become building blocks for health care quality improvement projects throughout the Nation. The 

reports undergo peer review prior to their release. 

 AHRQ expects that the EPC evidence reports and technology assessments will inform 

individual health plans, providers, and purchasers as well as the health care system as a whole by 

providing important information to help improve health care quality. 

 We welcome comments on this evidence report. They may be sent by mail to the Task Order 

Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, 

Rockville, MD 20850, or by e-mail to epc@ahrq.gov. 

Carolyn M. Clancy, M.D. Jean Slutsky, P.A., M.S.P.H. 

Director Director, Center for Outcomes and Evidence 

Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality 

Beth A. Collins Sharp, Ph.D., R.N. Marian D. James, Ph.D., M.A. 

Director, EPC Program EPC Program Task Order Officer 

Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality 
iv

Acknowledgments 

We thank Jessie McGowan and the Cochrane Effective Practice and Organisation of Care 

(EPOC) group for their help with the literature searches, Peter Pronovost, M.D., Ph.D. for 

providing a draft copy of an unpublished study, and Paul Cornia, MD for providing additional 

data from one study. We also acknowledge with much gratitude our expert advisors and peer 

reviewers who are listed in Appendix D*

.

 

*

 Appendixes cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/hainfgaptp.htm 
v

Structured Abstract 

Objective: To determine the effects of quality improvement strategies on promoting adherence 

to interventions for prevention of selected (surgical site infections (SSI), central line-associated 

bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and catheterassociated urinary tract infections (CAUTI)) healthcare-associated infections (HAIs), and on 

HAI rates. 

Data Sources: MEDLINE® and Cochrane Collaboration’s Effective Practice and Organisation 

of Care registry. We also reviewed the reference lists of systematic reviews and included 

studies, and contacted experts. 

Search Strategy and Inclusion Criteria: We included randomized and quasi-randomized 

controlled trials, controlled before-after studies, interrupted time series, and simple before-after 

studies that reported either HAI rates or rates of adherence to target preventive quality 

improvement (QI) interventions for any of the four target HAIs. QI strategies were classified as 

clinician education, patient education, audit and feedback, clinician reminders, organizational 

change (including revision of professional roles, staffing changes, and total quality 

management/continuous quality improvement), and financial or regulatory incentives. We 

targeted hand hygiene as a preventive intervention for all HAIs. The target preventive 

interventions specific to SSI were appropriate perioperative antibiotic prophylaxis (including 

appropriate antibiotic selection, timing, and duration), perioperative glucose control, and 

decreasing shaving of the operative site. For CLABSI, we targeted adherence to maximal sterile 

barrier precautions, use of chlorhexidine for skin antisepsis, and avoidance of femoral 

catheterization. For VAP, we targeted semirecumbent patient positioning and daily assessment 

of readiness for ventilator weaning. For CAUTI, we targeted reduction in unnecessary catheter 

use and adherence to aseptic catheter insertion and catheter care. Our primary outcomes were 

the rate of HAI (defined as infections per 100 cases for SSI and infections per 1,000 device-days 

for CLABSI, VAP, and CAUTI) and the rate of adherence to preventive interventions (defined as 

the percentage of patients at risk who received the preventive intervention). Secondary outcomes 

included effects on costs and adverse effects associated with the interventions. 

Data Collection and Analysis: Two reviewers independently abstracted data. Due to 

heterogeneity in study populations, QI strategies, preventive interventions, and outcomes, no 

formal quantitative analysis was attempted. We assessed study quality based on prespecified 

criteria for internal and external validity. 

Main Results: Sixty-four studies met all inclusion criteria; 28 studies addressed prevention of 

SSI, 19 CLABSI prevention, 12 VAP prevention, and 10 CAUTI prevention. Three studies 

targeted prevention of multiple HAIs. The study methodologic quality was generally poor, as 52 

of 64 included studies were simple before-after studies, and most of these (33 of 52) reported 

data at only one time point before and after the intervention. The majority of included studies 

reported infection rates, but did not report rate of adherence to preventive interventions. 
vi

Baseline HAI rates were generally above the median rates reported by the Centers for Disease 

Control and Prevention’s National Nosocomial Infection Surveillance System (NNIS). 

Studies addressing surgical site infections: The majority of studies targeted provision of 

appropriate antibiotic prophylaxis (22 of 28 studies), using combinations of educational 

interventions, audit and feedback, and clinician reminders. Sixteen of these studies reported data 

on adherence to appropriate antibiotic prophylaxis guidelines. Clinician reminders were 

effective at improving appropriate prophylaxis in two controlled studies; educational 

interventions with audit and feedback were effective in three multicenter studies (two interrupted 

time series and one simple before-after study.) No QI strategies were clearly effective at 

reducing SSI rates or improving adherence to other targeted preventive interventions. 

Studies addressing central line-associated bloodstream infection: Active educational 

interventions for clinicians appeared effective at reducing CLABSI rates, based on two 

controlled before-after studies, one interrupted time series, and four simple before-after studies 

of relatively good methodologic quality. Two of these studies combined education with an 

explicit checklist for adherence to insertion site practices and allowed nurses to stop the 

procedure if the checklist was not followed, a strategy worthy of future study. 

Studies addressing ventilator-associated pneumonia: Active educational interventions 

(including use of web-based and video tutorials) appeared to reduce VAP rates, based on 

evidence from two simple before-after studies. Conclusions in this area are especially limited as 

we did not identify any controlled studies. 

Studies addressing catheter-associated urinary tract infection: Printed or computer-based 

reminders to physicians, coupled with an “automatic stop order”, appear to be effective at 

reducing the duration of urethral catheterization (based on two controlled studies and three 

simple before-after studies.) 

Conclusion: The evidence for quality improvement strategies to improve adherence to 

preventive interventions for healthcare-associated infections is generally of suboptimal quality, 

consisting primarily of single-center, simple before-after studies of limited internal and external 

validity. Thus, we were unable to reach any firm conclusions regarding actionable QI strategies 

to prevent HAIs. Based on the limited available data, we suggest that the following strategies are 

worthy of future study, and possibly wider implementation: use of printed or computer-based 

reminders with automatic stop orders to reduce unnecessary urethral catheterization, printed or 

computer-based reminders to improve surgical antibiotic prophylaxis, active educational 

interventions with use of of checklists to improve adherence to central line insertion practices, 

and active educational interventions such as tutorials to improve adherence to preventive 

interventions for ventilator-associated pneumonia. Higher quality studies of QI strategies for 

HAI prevention are urgently needed. 

 
vii

Contents 

Executive Summary........................................................................................................................ 1 

Chapter 1. Introduction .................................................................................................................. 9 

Major Healthcare-Associated Infections................................................................................... 9 

Surgical Site Infections..................................................................................................... 10

Central Line-Associated Bloodstream Infections ............................................................. 15 

Ventilator-Associated Pneumonia .................................................................................... 16 

Catheter-Associated Urinary Tract Infection.................................................................... 16 

Research Questions................................................................................................................. 17 

Chapter 2. Methods...................................................................................................................... 19 

Scope....................................................................................................................................... 19 

Definitions of QI Terms Used in This Report ........................................................................ 19 

Classification of Interventions and Quality Improvement Strategies..................................... 19 

Targeted Preventive Interventions .................................................................................... 20 

Inclusion and Exclusion Criteria............................................................................................. 22

Literature Search and Review Process.................................................................................... 22 

Outcome Measures.................................................................................................................. 23 

Measurement Issues Specific to Studies of Healthcare-Associated Infections ...................... 23 

Quality Issues Specific to Studies of Healthcare Associated Infections................................. 24 

Factors Affecting the Internal Validity of the Studies...................................................... 24 

Factors Affecting the External Validity of the Studies..................................................... 25 

Analysis................................................................................................................................... 26 

Chapter 3. Results ........................................................................................................................ 27 

Surgical Site Infections........................................................................................................... 28 

Included Studies: Settings, Goals, and Target Populations ............................................. 28 

Baseline Infection Rates in U.S. and non-U.S. Studies .................................................... 28 

Preventive Interventions and Outcomes Measured........................................................... 29 

Quality Improvement Strategies ....................................................................................... 29 

Methodological Quality of Included Studies .................................................................... 29 

Studies Addressing Use of Appropriate Antibiotic Prophylaxis ...................................... 30 

Studies Not Using Appropriate Antibiotic Prophylaxis as an Outcome........................... 41 

Central Line-Associated Bloodstream Infections ................................................................... 51 

Included Studies: Settings, Goals, and Target Populations ............................................. 51 

Preventive Interventions and Outcomes Measured........................................................... 51 

Quality Improvement Strategies Used.............................................................................. 51 

Study Methodologic Quality............................................................................................. 52 

Ventilator-Associated Pneumonia .......................................................................................... 71 

Included Studies: Settings, Goals, and Target Populations ............................................. 71 

Preventive Interventions and Outcomes Measured........................................................... 72 

Quality Improvement Strategies ....................................................................................... 72 
viii

Methodologic Quality of Included Studies....................................................................... 72 

Catheter-Associated Urinary Tract Infection.......................................................................... 84 

Included Studies: Settings, Goals, and Target Populations ............................................. 84 

Preventive Interventions and Measured Outcomes........................................................... 84 

Quality Improvement Strategies ....................................................................................... 84 

Methodologic Quality of Included Studies....................................................................... 84 

Studies Addressing Reduction in Catheter Usage ............................................................ 85 

Studies Addressing Catheter Care .................................................................................... 89 

Chapter 4. Discussion .................................................................................................................. 93 

Surgical Site Infection............................................................................................................. 93 

Central Line-Associated Bloodstream Infections ................................................................... 93 

Ventilator-Associated Pneumonia .......................................................................................... 94 

Catheter-Associated Urinary Tract Infection.......................................................................... 94 

Limitations .............................................................................................................................. 94 

Conclusions............................................................................................................................. 96 

References and Included Studies .................................................................................................. 99 

List of Acronyms/Abbreviations................................................................................................. 107 

Figures 

Figure 1. Search results and article triage ...................................................................................27 

Tables 

Table 1. CDC/NNIS definitions for nosocomial infections, 2004.............................................11 

Table 2. Recommended preventive interventions......................................................................14 

Table 3. Quality Improvement Strategies ..................................................................................20 

Table 4a. Articles addressing prevention of surgical site infections (studies addressing 

use of appropriate antibiotic prophylaxis): controlled studies....................................31 

Table 4b. Articles addressing prevention of surgical site infections (studies addressing 

use of appropriate antibiotic prophylaxis): interrupted time series ............................34 

Table 4c. Articles addressing prevention of surgical site infections (studies addressing 

use of appropriate antibiotic prophylaxis): before-after studies with good 

methodological quality.................................................................................................35 

Table 4d. Articles addressing prevention of surgical site infections (studies addressing 

use of appropriate antibiotic prophylaxis): before-after studies with moderate 

methodological quality.................................................................................................36 

Table 4e. Articles addressing prevention of surgical site infections (studies addressing 

use of appropriate antibiotic prophylaxis): before-after studies with poor 

methodological quality.................................................................................................38 

Table 4f. Articles addressing prevention of surgical site infections (studies not using 

appropriate antibiotic prophylaxis as an outcome): controlled studies.......................42 
ix

Table 4g. Articles addressing prevention of surgical site infections (studies not using 

appropriate antibiotic prophylaxis as an outcome): simple before-after 

studies of moderate methodologic quality ...................................................................43 

Table 4h. Articles addressing prevention of surgical site infections (studies not using 

appropriate antibiotic prophylaxis as an outcome): simple before-after 

studies of poor methodologic quality...........................................................................46 

Table 5. Quality criteria for simple before-after studies addressing surgical 

site infections ...............................................................................................................50 

Table 6a. Articles adressing prevention of central line-associated bloodstream 

infections (CLABSI): controlled studies ....................................................................53 

Table 6b. Articles adressing prevention of central line-associated bloodstream 

infections: interrupted time series...............................................................................57 

Table 6c. Articles adressing prevention of central line-associated bloodstream 

infections: simple before-after studies of good methodologic quality........................60 

Table 6d. Articles adressing prevention of central line-associated bloodstream 

infections: simple before-after studies of moderate methodologic quality.................65 

Table 6e. Articles adressing prevention of central line-associated bloodstream 

infections: simple before-after studies of poor methodologic quality ........................66 

Table 7. Quality criteria for simple before-after studies addressing central 

line-associated bloodstream infections ........................................................................71 

Table 8a. Articles addressing prevention of ventilator-associated pneumonia: 

simple before-after studies of good methodologic quality ..........................................74 

Table 8b. Articles addressing prevention of ventilator-associated pneumonia: 

simple before-after studies of moderate methodologic quality....................................77 

Table 8c. Articles addressing prevention of ventilator-associated pneumonia: 

simple before-after studies of poor methodologic quality ...........................................79 

Table 9. Other preventive interventions used in studies addressing ventilatorassociated pneumonia ..................................................................................................82 

Table 10. Quality criteria for simple before-after studies addressing ventilatorassociated pneumonia ..................................................................................................83 

Table 11a. Articles addressing prevention of catheter-associated urinary tract infections 

(studies addressing reduction in catheter usage): controlled studies ..........................86 

Table 11b. Articles addressing prevention of catheter-associated urinary tract infections 

(studies addressing reduction in catheter usage): simple before-after 

studies of moderate methodologic quality ...................................................................87 

Table 11c. Articles addressing prevention of catheter-associated urinary tract infections 

(studies addressing catheter care): controlled studies.................................................89 

Table 11d. Articles addressing prevention of catheter-associated urinary tract infections 

(studies addressing catheter care): simple before-after studies of moderate 

methodologic quality ...................................................................................................90 

Table 11e. Articles addressing prevention of catheter-associated urinary tract infections 

(studies addressing catheter care): simple before-after studies of poor 

methodologic quality ...................................................................................................91 

Table 12. Quality criteria for simple before-after studies addressing catheter-associated 

urinary tract infections .................................................................................................92 
x

Appendixes 

Appendix A: Literature Search Strategy 

Appendix B: Sample Data Abstraction Forms 

Stage 1 (Screening Title and Abstract) Form 

Stage 2 (Full Text) Abstraction Form 

Appendix C: Listing of Excluded Studies 

Appendix D: Technical Experts and Peer Reviewers 

Appendices and Evidence Tables for this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/qualgap6/hainfgap.pdf
1

Executive Summary 

Overview 

Healthcare-associated infections (HAIs) are considered to be the greatest risk posed to 

hospitalized patients; up to two million patients experience a healthcare-associated infection 

every year in the U.S., leading to approximately 88,000 deaths per year. Active efforts to curb 

HAIs have increased in recent years, thanks to the growing emphasis on patient safety and 

quality; these efforts include public reporting of infection rates in some states, and widely 

publicized campaigns to promote adherence to HAI preventive interventions (such as the 

Institute for Healthcare Improvement’s “100,000 Lives” campaign). 

Within the hospital, surgical site infections (SSI) and three types of infections common in 

intensive care unit (ICU) patients are particularly prevalent—central-line associated bloodstream 

infections (CLABSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary 

tract infections (CAUTI). Together, these infections account for more than 80 percent of all 

HAIs. In this report, we systematically review the evidence supporting quality improvement 

strategies to reduce the incidence of these key healthcare-associated infections. We intend to 

identify strategies that successfully increase adherence to effective preventive practices for each 

of these infections and reduce infection rates. Our specific research questions are: 

1. Do quality improvement strategies increase adherence to evidence-based preventive 

interventions for healthcare-associated infections? 

2. What are the critical components of effective QI strategies? 

3. What are the limitations of current research in this field, and what areas require 

further study? 

We defined a “preventive intervention” as a specific infection control practice that has been 

demonstrated to reduce the incidence of a HAI. To identify target preventive interventions, we 

reviewed the CDC guidelines for prevention of surgical site infection, prevention of intravascular 

catheter-related infections, prevention of healthcare-associated pneumonia, and prevention of 

catheter-associated urinary tract infection. Hand hygiene was identified as an important 

preventive intervention for all HAIs. The disease-specific target preventive interventions we 

identified are as follows: 

• Surgical site infection: appropriate perioperative antibiotic prophylaxis (including 

appropriate antibiotic selection, timing, and duration), perioperative glucose control, and 

decreasing shaving of the operative site. 

• Central line-associated bloodstream infection: adherence to maximal sterile barrier 

precautions, use of chlorhexidine for skin antisepsis, and avoidance of femoral 

catheterization. 

• Ventilator-associated pneumonia: semirecumbent patient positioning and daily 

assessment of readiness for ventilator weaning. 
2

• Catheter-associated urinary tract infection: reduction in unnecessary catheter use and 

adherence to aseptic catheter insertion and catheter care 

As in previous reviews in this series, we performed a rigorous search of the published 

literature using the MEDLINE® database, supplemented by targeted searches of the Cochrane 

Collaboration Effective Practice and Organisation of Care (EPOC) database. We included 

studies with contemporaneous control groups (randomized controlled trials and controlled 

before-after studies) and quasi-experimental studies without a contemporaneous control group 

(interrupted time series and simple before-after studies). We classified QI interventions 

according to a modification of a taxonomy used in previous volumes of this series. The QI 

strategies were classified as follows: 

1. Clinician education 

2. Patient education 

3. Audit and feedback 

4. Clinician reminder systems 

5. Organizational change 

6. Financial or regulatory incentives for patients or clinicians 

We included studies that used one or more of the above QI strategies to implement or 

increase use of any of the target preventive interventions. Included studies were required to 

report data on the rate of adherence to recommended preventive interventions and/or the rate of 

healthcare-associated infection. Trials that reported related outcomes, such as costs, health 

services utilization (e.g., length of stay), patient or provider satisfaction with care, or adverse 

events associated with the intervention, were included only if they included data on infection 

rates or adherence measures. 

We assessed study quality based on prespecified criteria for assessing study internal and 

external validity. These criteria were not used to determine study inclusion or exclusion. For 

simple before-after studies, we applied the following criteria: 

1. Was the intervention performed independent of other QI efforts or other changes?

2. Did the study report data at more than one time point before and after the intervention? 

3. If the study reported infection rates, were process measurements also reported? 

4. If the study reported infection rates, did the study use CDC/NNIS methodology for 

measuring infections? 

5. (For CLABSI, VAP, and CAUTI) If the study reported infection rates, were reported 

rates adjusted for device utilization? 

6. (For SSI) If the study reported infection rates, was surveillance for infections performed 

after hospital discharge? 

Studies reporting process measures (rate of adherence to target preventive interventions) 

were considered to have greater external validity, as these measures are universally applicable. 

For controlled studies, we also applied the following study quality criteria, as used in previous 

volumes of this series: 
3

1. Were study subjects randomized, and if so, was the randomization process described? 

2. For non-randomized studies, was the rationale for selection of the comparison group 

explained, and a baseline observation period included (to assess selection bias)? 

3. Were the outcome assessors blinded to treatment group assignment? 

4. Was a unit-of-analysis error present? If so, were appropriate statistical methods used for 

correction? 

We did not perform quantitative analysis, instead using our study quality criteria as a 

framework to identify studies of relatively stronger internal and external validity. 

Results 

Our search strategy identified a total of 4,847 citations, and one additional unpublished 

citation was identified from our peer review panel. Of these, 434 underwent full-text review, and 

64 articles met all criteria for inclusion. In general, baseline rates of HAIs were higher than rates 

reported by the Centers for Disease Control and Prevention’s National Nosocomial Infection 

Surveillance System (NNIS).

Surgical Site Infections 

Twenty-eight studies met all inclusion criteria and addressed prevention of surgical site 

infections. Most (19) of the studies were performed outside of the United States. Several QI 

strategies were used: 23 studies used clinician education, 15 used audit and feedback, 15 used 

organizational change strategies such as creation of multidisciplinary teams or adding additional 

staff, and five used clinician reminder systems. The methodological quality of studies was 

generally poor; 22 of 28 used a quasi-experimental simple before-after (SBA) design. Even 

within the limits of the study design, most SBA studies had poor internal and external validity, as 

most reported data on only one time point before and after the intervention, and most did not 

perform post-discharge surveillance. Ten studies used surgical site infection rate as the primary 

outcome, eight used process measures as primary outcomes, and eight both infection rates and 

process measures. The majority of studies (16 of 28) reported data on adherence to appropriate 

antibiotic prophylaxis protocols. Limited data indicate that educational interventions coupled 

with audit and feedback may be effective at improving adherence to appropriate antibiotic 

prophylaxis. Clinician reminders may also improve perioperative antibiotic prophylaxis, 

especially when incorporated into a CPOE system. No conclusion can be reached regarding the 

effectiveness of QI strategies at promoting perioperative glucose control, perioperative 

normothermia, or decreasing operative site shaving. We were unable to determine any strategies 

effective at reducing SSI rates. In studies that did not have important methodologic flaws, 

surgical site infection rates were not consistently reduced, even when process measurements 

were improved. 

Central Line-Associated Bloodstream Infections 

Our literature search identified 19 studies that met our inclusion criteria that specifically 

addressed prevention of central line-associated blood stream infection (CLABSI). Ten were 
4

from centers within the United States. All but one of the studies was from a single center. All of 

the studies reported rates of CLABSI; nine of the studies also reported data on adherence 

measures. All studies but one targeted hand hygiene; five studies targeted hand hygiene alone, 

four targeted hand hygiene and maximal sterile barrier precautions, and seven studies targeted 

hand hygiene, maximal sterile barrier precautions, and at least one other preventive strategy. All 

but one of the studies employed educational strategies for health care providers as part of their 

intervention, targeting nurses and physicians. The majority of educational interventions were 

active in nature. Eight studies employed audit and feedback, five employed strategies that 

included organizational change, and four used clinician reminders. The majority of studies used 

a multifaceted approach, incorporating more than one QI strategy. The methodological quality of 

studies was also poor, as all but two used an SBA design, and the majority of these reported data 

at one time point before and after the intervention and failed to report both infection rates and 

adherence measures. Seven studies (including two controlled studies) used active educational 

interventions, including demonstrations and self-study tutorials to improve adherence to 

preventive practices during catheter insertion and reduce CLABSI rates. Two of these studies 

used an explicit checklist during central line insertion, with nurses empowered to stop the 

procedure if all preventive interventions were not used, and documented marked reductions in 

CLABSI rates. These educational interventions have been evaluated in teaching and nonteaching hospitals, and in U.S. and European institutions, increasing their generalizability. We 

were unable to judge the effectiveness of any other QI strategies at either improving adherence 

or reducing CLABSI rates. 

Ventilator-Associated Pneumonia

We identified 12 articles meeting our inclusion criteria that assessed prevention of ventilatorassociated pneumonia. Studies were mostly performed in the United States, primarily in a single 

institution. All but one included studies explicitly promoted hand hygiene, and eight promoted 

semirecumbent patient positioning; two studies promoted daily assessment of readiness to wean 

from the ventilator. Many other preventive interventions were used in the studies, including 

aseptic drainage of ventilator circuit condensate, appropriate suctioning technique, and provision 

of oral care. All studies primarily used educational interventions targeted at providers 

(physicians, nurses, and respiratory therapists.) Most of these combined use of written materials 

and lectures, with six studies implementing an explicit clinical guideline for preventive care. 

Three studies used audit and feedback of infection rates, and two used a continuous quality 

improvement intervention. The methodologic quality of studies was generally poor, as all used a 

SBA design, and (similar to CLABSI studies) most reported data at one time point before the 

intervention and did not report both adherence measures and infection rates. Two studies used 

an active educational intervention with use of a self-study module for ICU staff, and documented 

significant reductions in VAP rates; this appears to be a promising strategy for reducing VAP. 

These studies implemented explicit clinical guidelines for preventing VAP. No conclusion can 

be reached on the effectiveness of audit and feedback of VAP rates, or on the effectiveness of 

any other QI strategies. 
5

Catheter-Associated Urinary Tract Infection

Our search identified ten articles that addressed prevention of catheter-associated urinary tract 

infections, six of which were performed outside the United States. Of the included studies, six 

addressed reduction in placement of catheters or removal of unnecessary catheters once already 

placed, four addressed aseptic insertion and catheter care, and two hand hygiene. Six studies 

used a printed or computer-based reminder to attempt to reduce unnecessary catheter use. Six 

studies used provider education, two used audit and feedback, and two used an organizational 

change strategy whereby nurses were authorized to remove urethral catheters without a physician 

order. Seven studies measured CAUTI rate (symptomatic CAUTI or asymptomatic bacteriuria). 

Four studies measured catheter usage, reported as the percentage of inpatients catheterized or the 

average duration of catheterization. We identified three controlled before-after studies and seven 

simple before-after studies. The CBA studies were generally of fair methodologic quality, and 

the SBA studies were generally of relatively poor quality, with similar problems with internal 

and external validity as for the other HAIs. Within these limitations, reminders to clinicians 

appear to be effective at reducing unnecessary catheter usage, primarily by reducing the duration 

of catheterization. Three of these studies incorporated an “automatic stop order” mandating 

removal of the catheter after 48 to 72 hours unless countermanded by the physician, and all 

documented a reduction in catheter use and CAUTI rate. We were unable to assess the 

effectiveness of any other QI strategies. 

Across all four target HAIs, the quality of the included studies was generally poor, as 52 of 

64 included studies used a SBA design. Even within the limitations of this study design, most 

studies had poor internal validity, chiefly due to reporting data at only one time point before and 

after the intervention. Generalizability was also poor, as the baseline level of HAI rates were 

well above the pooled NNIS mean for CLABSI, VAP, and CAUTI. The relatively high baseline 

rates raise the concern that the observed improvement could be due to regression to the mean 

(especially in SBA studies). Most studies also reported infection rates without reporting 

accompanying adherence measures. Publication bias is likely, as most (30 of 39) of the studies 

reporting adherence to preventive interventions reported a statistically significant improvement 

in adherence. Other methodologic problems in the included studies are similar to those 

identified in previous volumes in this series, such as inadequate reporting of intervention details 

and failure to report the reach of an intervention. No studies performed a formal cost-benefit 

analysis, and few studies reported on any potential adverse effects of the intervention. We were 

unable to perform any quantitative analyses. 

Conclusions 

We are unable to make firm recommendations for organizations seeking to implement quality 

improvement interventions to reduce healthcare-associated infections. Based on the limited data 

available, we reach the following conclusions: 

1. Preliminary data indicates that several strategies are worthy of future study, and 

possibly wider implementation. 
6

There is insufficient data to support universal implementation of these strategies, but they 

may be suitable for implementation if an appropriate plan is in place to monitor their 

effectiveness and potential adverse effects: 

• Printed or computer-based reminders with use of automatic stop orders to reduce 

unnecessary urethral catheterization (the only strategy supported by multiple controlled 

trials); 

• Printed or computer-based reminders for improving adherence to recommendations for 

timing and duration of surgical antibiotic prophylaxis; 

• Staff education, including use of interactive tutorials (including video and web-based) 

and checklists, to improve adherence to insertion practices for placement of central 

venous catheters; 

• Staff education, including use of interactive tutorials, to improve adherence to preventive 

interventions to prevent ventilator-associated pneumonia. 

2. Higher quality studies of QI strategies to implement preventive interventions are 

urgently needed. 

Investigators should attempt to perform controlled trials of QI strategies when possible, and 

should report both adherence measures and infection rates. If performing a controlled trial is 

impractical, investigators should perform interrupted time series studies, involving reporting data 

for at least 3 time points before and after the intervention and formal time series statistical 

analysis. Given the burden of disease caused by healthcare-associated infections, prioritizing 

study of methods to implement effective preventive interventions should greatly benefit 

hospitalized patients. 
Technical Review 

9

Chapter 1. Introduction 

Healthcare-associated infections (HAIs) are considered to be the greatest risk patients face in 

the hospital environment. HAIs can occur in any patient care setting, but infections in 

hospitalized patients account for the vast majority of HAIs. Hospitalized patients are 

additionally susceptible to experiencing serious consequences of HAIs due to comorbid illnesses. 

According to estimates from the Centers for Disease Control and Prevention (CDC), up to two 

million patients (nearly one in 20 hospitalized patients) experience a healthcare-associated 

infection every year in the U.S., leading to approximately 88,000 deaths and $4.5 billion in extra 

costs per year. Moreover, the incidence of HAIs appears to have increased over the last three 

decades,1

 despite the fact that the majority of HAIs are thought to be preventable.2

Efforts to monitor and prevent HAIs have existed for decades. These efforts have followed 

the public health methodology of surveillance and prevention. The effectiveness of such 

methods was provided by the Study of the Effectiveness of Nosocomial Infection Control 

(SENIC) study,3

 which demonstrated that hospitals with structured infection control programs 

achieved sustained reductions in HAI rates, whereas hospitals with less comprehensive programs 

saw increased infection rates. 

The growing focus on improving patient safety over the past few years has catalyzed even 

greater efforts to curb HAIs. Public reporting of infection rates has been proposed as a means of 

educating patients and encouraging preventive efforts;4 currently, six states require reporting of 

HAIs, and legislation requiring some type of reporting has been proposed in the majority of 

states. The Healthcare Infection Control Practices Advisory Committee (HICPAC) recently 

published guidance on the public reporting of healthcare associated infections, which suggested 

that central line insertion practices and infection rates, surgical antimicrobial prophylaxis and 

infection rates, and influenza vaccination coverage among patients and healthcare personnel are 

areas that may be appropriate for public reporting.5 These efforts are in parallel to those already 

being undertaken by many national and international organizations. The Joint Commission for 

Accreditation of Healthcare Organizations (JCAHO) has made prevention of HAI one of their 

Patient Safety Goals for 2007.6

 The Institute for Healthcare Improvement (IHI) made the 

institution of practices to prevent HAIs (specifically surgical site infections, central lineassociated bloodstream infections, and ventilator-associated pneumonia) three of the six ”planks” 

of their “100,000 Lives” campaign.7 These preventive interventions were organized into 

“bundles”, in an effort to promote complete adherence with all of the recommended interventions 

for all eligible patients. The IHI’s recent press statements that over 122,000 “lives were saved” 

at hospitals participating in the campaign, though methodologically controversial, is likely to 

increase the enthusiasm for implementing these and the other recommended practices. Finally, 

prevention of HAIs was recognized as one of the 20 “Priority Areas for National Action” in the 

2003 Institute of Medicine report, “Transforming Health Care Quality”.8

 

Major Healthcare-Associated Infections 

Within the hospital, infections in surgical patients and infections in intensive care unit (ICU) 

patients are particularly prevalent. The Harvard Medical Practice Study II9

 found that surgical 

site infections (SSI) were the second most common overall adverse event (behind only adverse 

drug events) in all hospitalized patients. The incidence of HAI in ICU patients has been 
10

estimated to be as high as 30 percent,10 and 25 percent of all HAIs are estimated to occur in ICU 

patients.11 Surgical site infections (SSI) and three other types of infections commonly seen in 

ICU patients—central-line associated bloodstream infections (CLABSI), catheter-associated 

urinary tract infections (CAUTI), and ventilator-associated pneumonia (VAP)—account for more 

than 80 percent of all HAIs.10 

Data on the incidence of HAIs in U.S. hospitals primarily comes from the CDC’s National 

Nosocomial Infection Surveillance System (NNIS). The NNIS consists of over 300 hospitals 

which voluntarily report data on several types of nosocomial infections (including SSI, CLABSI, 

VAP, and CAUTI), using standardized reporting criteria. Data from NNIS are important for use 

in benchmarking,12 although the data are not intended for use in direct hospital-to-hospital 

comparison of infection rates. The pathogenesis, incidence, and prevention of these HAIs are 

briefly outlined below. 

Surgical Site Infections 

Surgical site infections (SSIs) frequently complicate operations, with an estimated annual 

incidence of 780,000 cases per year.13 The Centers for Disease Control and Prevention (CDC) 

publishes a widely used set of diagnostic criteria for each type of SSI: superficial incisional, deep 

incisional and organ space infections (Table 1). The 2004 NNIS report published mean SSI rates 

that ranged from 0.45 per 100 cases for low-risk cholecystectomy to 11.25 per 100 cases for 

high-risk colorectal surgery.14 For example, in coronary artery bypass graft (CABG) operations, 

the rate for average-risk patients was 3.45/100 cases. In the same group of patients, the rate of 

superficial infections was 1.87/100 cases, the rate of deep incisional infections was 0.89/100 

cases and the rate of organ space infections was 0.68/100 cases. SSIs increase length of stay and 

costs substantially. One study estimated that each SSI increased hospital charges by $4,768 

(2006 dollars).15 Another study estimated that patients diagnosed with SSIs after discharge 

incurred $3,696 in additional outpatient costs (2006 dollars).16

Several organizations, including the CDC, the National Surgical Infection Prevention Project 

(NSIPP) and the Surgical Care Improvement Project (SCIP), have proposed preventive 

interventions to reduce the incidence of SSIs. The CDC strongly recommends several preventive 

measures that are well supported in the literature (Table 2) and are also recommended by NSIPP 

and SCIP.13 However, adherence to these practices remains suboptimal, including that of the 

best-studied preventive practice, antimicrobial prophylaxis. The current guidelines recommend 

three aspects of antimicrobial prophylaxis: appropriate timing, appropriate selection, and 

appropriate duration. 

Appropriate timing consists of administration of antimicrobial prophylaxis within one hour 

before the surgical incision (or within two hours if a flouroquinolone or vancomycin is used); 

appropriate selection refers to using antibiotics effective against the pathogens likely to be 

encountered in a specific type of surgery (e.g., cefazolin for hip or knee arthroplasty); and 

appropriate duration of therapy mandates discontinuing antibiotics within 24 hours after 

surgery.13, 17 Adherence to these measures in practice is suboptimal. A retrospective study of 

over 30,000 Medicare patients published in 2005 found that prophylaxis was given within one 

hour of incision in only 55.7 percent of patients and discontinued within 24 hours of surgery in 

40.7 percent of patients; guideline-concordant therapy was appropriately used in 92.6 percent of 

patients.18 These data indicate that improving antimicrobial prophylaxis practices, particularly 

antibiotic timing, has the potential to positively impact SSI rates. Several groups, including the 
11

Institute for Healthcare Improvement (IHI) and the Surgical Care Improvement Project (SCIP) 

have tried to promote use of these practices nationwide.19 

Table 1. CDC/NNIS definitions for nosocomial infections, 2004 

Infection Definition 

Surgical site 

infections 

(SSI) 

Superficial Incisional Infections: 

A superficial SSI must meet the following criteria: 

Infection occurs within 30 days after the operative procedure and involves only skin and 

subcutaneous tissue of the incision and patient has at least one of the following: 

a. Purulent drainage from the superficial incision 

b. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial 

incision 

c. At least one of the following signs or symptoms of infection: pain or tenderness, localized 

swelling, redness, or heat, and superficial incision is deliberately opened by surgeon, unless

incision is culture-negative 

d. Diagnosis of superficial incisional SSI by the surgeon or attending physician 

Deep Incisional SSI 

A deep incisional SSI must meet the following criteria: 

Infection occurs within 30 days after the operative procedure if no implant is left in place or 

within one year if implant is in place and the infection appears to be related to the operative 

procedure and involves deep soft tissues (e.g., fascial and muscle layers) of the incision and 

patient has at least one of the following: 

a. Purulent drainage from the deep incision but not from the organ/space component of the 

surgical site 

b. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the 

patient has at least one of the following signs or symptoms: fever (>38°C) or localized pain or 

tenderness, unless incision is culture-negative 

c. An abscess or other evidence of infection involving the deep incision is found on direct 

examination, during reoperation, or by histopathologic or radiologic examination 

d. Diagnosis of a deep incisional SSI by a surgeon or attending physician 

Organ/Space SSI: 

An organ/space SSI involves any part of the body, excluding the skin incision, fascia, or 

muscle layers, that is opened or manipulated during the operative procedure. An example is 

appendectomy with subsequent subdiaphragmatic abscess, which would be reported as an 

organ/space SSI at the intraabdominal specific site. An organ/space SSI must meet the 

following criteria: 

Infection occurs within 30 days after the operative procedure if no implant is left in place or 

within 1 year if implant is in place and the infection appears to be related to the operative 

procedure and infection involves any part of the body, excluding the skin incision, fascia, or 

muscle layers, that is opened or manipulated during the operative procedure and patient has 

at least one of the following: 

a. Purulent drainage from a drain that is placed through a stab wound into the organ/space 

b. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space 

c. An abscess or other evidence of infection involving the organ/space that is found on direct 

examination, during reoperation, or by histopathologic or radiologic examination 

d. Diagnosis of an organ/space SSI by a surgeon or attending physician 

Central lineassociated 

bloodstream 

infections (CLABSI) 

Patient must have had an indwelling central venous catheter in place at the time of, or 

within 48 hours of the onset of the event. 

Laboratory Confirmed Bloodstream Infection (LCBI) 

LCBI criteria may be used for all patients. LCBI must meet at least one of the following 

three criteria: 

Criterion 1: Patient has a recognized pathogen cultured from one or more blood cultures and 

organism cultured from blood is not related to an infection at another site. 
12

Table 1. CDC/NNIS definitions for nosocomial infections, 2004 (continued)

Infection Definition 

Central lineassociated 

bloodstream 

infections (CLABSI) 

Criterion 2: Patient has at least one of the following signs or symptoms: fever (>38°C), chills, 

or hypotension and signs and symptoms and positive laboratory results are not 

related to infection at another site and at least one of the following:

a. common skin contaminant (e.g., diphtheroids, Bacillus sp., Propionibacterium sp., 

coagulase-negative staphylococci, or micrococci) is cultured from two or more blood cultures 

drawn on separate occasions 

b. common skin contaminant (e.g., diphtheroids, Bacillus sp., Propionibacterium sp., 

coagulase-negative staphylococci, or micrococci) is cultured from at least one blood culture 

from a patient with an intravascular line, and physician institutes appropriate antimicrobial 

therapy 

c. positive antigen test on blood (e.g., H. influenzae, S. pneumoniae, N. meningitidis, or Group 

B Streptococcus). 

Criterion 3: Patient < 1 year of age has at least one of the following signs or symptoms: 

fever (>38°C, rectal), hypothermia (<37°C, rectal), apnea, or bradycardia and signs and 

symptoms and positive laboratory results are not related to an infection at another site 

and at least one of the following: 

a. common skin contaminant (e.g., diphtheroids, Bacillus sp., Propionibacterium sp., 

coagulase-negative staphylococci, or micrococci) is cultured from two or more blood cultures 

drawn on separate occasions 

b. common skin contaminant (e.g., diphtheroids, Bacillus sp., Propionibacterium sp., 

coagulase-negative staphylococci, or micrococci) is cultured from at least one blood culture 

from a patient with an intravascular line, and physician institutes appropriate antimicrobial 

therapy

c. positive antigen test on blood or urine (e.g., H. influenzae, S. pneumoniae, N. meningitidis, 

or Group B Streptococcus). 

Clinical Sepsis (CSEP): CSEP may be used only to report a primary BSI in neonates and 

infants. To report a CSEP, the following criterion must be met:

Patient ≤ 1 year of age has at least one of the following clinical signs or symptoms with no 

other recognized cause: fever (>38°C, rectal), hypothermia (<37°C, rectal), apnea, or 

bradychardia and blood culture not done or no organisms or antigen detected in blood and no 

apparent infection at another site and physician institutes treatment for sepsis. 

Ventilatorassociated 

pneumonia (VAP) 

PNU 1: Clinically defined pneumonia (in mechanically ventilated patient) 

Radiographic criteria: 

Two or more serial chest radiographs with at least one of the following: 

New or progressive and persistent infiltrate 

Consolidation 

Cavitation 

Pneumatoceles, in infants <1 year old 

NOTE: In patients without underlying pulmonary or cardiac disease, one definitive chest 

radiograph is acceptable. 

Clinical Criteria: 

For any patient, at least one of the following: 

a. Fever (>38°C or >100.4°F) with no other recognized cause 

b. Leukopenia (<4,000 WBC/mm3) or leukocytosis (>12,000 WBC/mm3) 

For adults >70 years old, altered mental status with no other recognized cause and at least 

two of the following: 

c. New onset of purulent sputum, or change in character of sputum, or increased respiratory 

secretions, or increased suctioning requirements 

d. New onset or worsening cough, or dyspnea, or tachypnea 

e. Rales or bronchial breath sounds 

f. Worsening gas exchange, increased oxygen requirements, or increased ventilation demand) 

Catheter-associated 

urinary tract 

infection (CAUTI) 

Symptomatic urinary tract infection: 

Criterion 1: Patient has at least one of the following signs or symptoms with no other 

recognized cause: fever (>38°C), urgency, frequency, dysuria, or suprapubic tenderness and 

patient has a positive urine culture, that is, >105 microorganisms per cm3

 of urine with no more 

than two species of microorganisms. 
13

Table 1. CDC/NNIS definitions for nosocomial infections, 2004 (continued)

Infection Definition 

Criterion 2: Patient has at least two of the following signs or symptoms with no other 

recognized cause: fever (>38°C), urgency, frequency, dysuria, or suprapubic tenderness and 

at least one of the following: 

a. Positive dipstick for leukocyte esterase and/or nitrate. Pyuria (urine specimen with >10 

WBC/mm3

 or >3 WBC/high power field of unspun urine) 

c. Organisms seen on Gram stain of unspun urine 

d. At least two urine cultures with repeated isolation of the same uropathogen (gram-negative 

bacteria or S. saprophyticus) with >102

 colonies/mL in nonvoided specimens 

e. >105

 colonies/mL of a single uropathogen (gram-negative bacteria or S. saprophyticus) in a 

patient being treated with an effective antimicrobial agent for a urinary tract infection 

f. Physician diagnosis of a urinary tract infection 

g. Physician institutes appropriate therapy for a urinary tract infection 

Criterion 3: Patient <1 year of age has at least one of the following signs or symptoms with 

no other recognized cause: fever (>38°C), hypothermia (<37°C), apnea, bradycardia, dysuria, 

lethargy, or vomiting and patient has a positive urine culture, that is, >105

 microorganisms per 

cm3

 of urine with no more than two species of microorganisms. 

Criterion 4: Patient <1 year of age has at least one of the following signs or symptoms with 

no other recognized cause: fever (>38°C), hypothermia (<37°C), apnea, bradycardia, dysuria, 

lethargy, or vomiting and at least one of the following: 

a. Positive dipstick for leukocyte esterase and/or nitrate 

b. Pyuria (urine specimen with >10 WBC/mm3

 or >3 WBC/high power field of unspun urine) 

c. Organisms seen on Gram stain of unspun urine 

d. At least two urine cultures with repeated isolation of the same uropathogen (gram-negative 

bacteria or S. saprophyticus) with >102

 colonies/mL in nonvoided specimens 

e. >105

 colonies/mL of a single uropathogen (gram-negative bacteria or S. saprophyticus) in a 

patient being treated with an effective antimicrobial agent for a urinary tract infection 

f. Physician diagnosis of a urinary tract infection 

g. Physician institutes appropriate therapy for a urinary tract infection 

Catheter-associated asymptomatic bacteriuria: 

Criterion 1: Patient has had an indwelling urinary catheter within 7 days before the culture 

and patient has a positive urine culture, and patient has no fever (>38°C), urgency, 

frequency, dysuria, or suprapubic tenderness. 
14

Table 2. Recommended preventive interventions 

Healthcareassociated 

infection 

Preventive 

intervention Definition 

Level of 

supporting 

evidence 

Notes 

All target HAIs Hand hygiene Washing hands before and 

after each patient contact 

I Universally recommended 

as key strategy to present 

HAIs of all types. Current 

recommendations 

encourage use of waterless, 

alcohol-based hand rubs. 

Central lineassociated 

bloodstream 

infections 

(CLABSI) 

Maximal sterile 

barrier 

precautions 

Use aseptic technique 

including the use of a cap, 

mask, sterile gown, sterile 

gloves, and a large sterile 

sheet for the insertion of all 

central venous catheters 

(CVC) 

I 

 Chlorhexidine 

skin antisepsis 

Use 2% chlorhexidine 

gluconate solution for skin 

disinfection at the CVC 

insertion site 

I 

 Appropriate 

insertion site 

selection 

Avoid femoral site for nonemergency CVC insertion I CVC insertion at the internal 

jugular or subclavian site is 

preferred. 

 Prompt removal 

of unnecessary 

catheters 

Removal of CVC that is no 

longer essential for care 

I Routine removal of CVC and 

routine replacement of CVC 

over guidewire are explicitly 

discouraged. 

Surgical site 

infection (SSI) 

Appropriate use 

of perioperative 

antibiotics 

Administration of appropriate 

prophylactic antibiotic with 

correct timing and duration 

I Generally defined as 1st

generation cephalosporin 

administered within 1 hour 

prior to surgical incision and 

discontinued within 24 hours 

 Avoidance of 

shaving of the 

operative site 

 I Use of clippers encouraged 

when necessary 

 Perioperative 

glucose control 

Maintenance of blood glucose 

<150mg/dl during 

postoperative period (tighter 

control may be more 

beneficial in specific patient 

populations) 

I Especially important for 

patients undergoing 

coronary artery bypass 

grafting 

Ventilatorassociated 

pneumonia 

(VAP) 

Semirecumbent 

positioning 

Elevation of the head of the 

bed to more between 30 and 

45 degrees 

I 

 Daily assessment 

of readiness for 

weaning 

Minimize duration of 

mechanical ventilation by 

minimizing sedative 

administration (including daily 

“sedation holidays”) and/or 

using protocolized weaning 

II 
15

Table 2. Recommended preventive interventions (continued) 

Healthcareassociated 

infection 

Preventive 

intervention Definition 

Level of 

supporting 

evidence 

Notes 

Catheterassociated 

urinary tract 

infection 

(CAUTI) 

Aseptic insertion 

and catheter care 

Use of skin antisepsis at 

insertion and proper aseptic 

technique for maintenance of 

catheter and drainage bag; 

use of closed urinary 

drainage system 

I 

Reduction in 

unnecessary 

catheter use 

Avoiding use of catheter 

unless clinically indicated; 

prompt removal of catheters 

when indications for use are 

no longer present 

I Generally accepted 

indications for urethral 

catheterization include 

bladder outlet obstruction, 

urinary incontinence, need 

for frequent urine output 

monitoring, and 

postoperative state. 

Duration of catheterization is 

a significant risk factor for 

CAUTI, and unnecessary 

catheterization is common. 

Level of supporting evidence: 

I: Level IA recommendation by Centers for Disease Control and Prevention, or Level I recommendation by Infectious Diseases 

Society of America/American Thoracic Society. 

II: Level II recommendation by Infectious Diseases Society of America/American Thoracic Society. 

Central Line-Associated Bloodstream Infections 

More than five million central venous catheters (CVC) are inserted into patients in the U.S. 

every year.20 Several types of infections can occur in patients with CVCs. The skin at the 

insertion site of the catheter may become infected (so-called exit-site infection). The internal 

surface of the device itself may become colonized with bacteria, which occurs in 25 percent of 

catheters left in place for five days. The clinical significance of colonization alone is unclear, but 

(along with migration of skin flora along the external surface of the catheter) it predisposes to the 

most serious consequence of catheter-related infection—central-line associated bloodstream 

infection (CLABSI),21 when a patient develops bacteremic infection associated with the presence 

of a CVC. It is estimated that one of the two types of infection above (exit-site infection or 

CLABSI) occur in 3-7 percent of catheters,21 resulting in approximately 80,000 episodes of 

CLABSI in the U.S. every year.11 Most of these infections occur in patients with temporary 

central venous catheters, often placed in ICU patients. CLABSI are estimated to result in an 

absolute increase in mortality of 10-30 percent for ICU patients,10, 22, 23 and the total yearly costs 

to the U.S. health care system are between $300 million and $2 billion.11

CLABSI are measured according to criteria established by the CDC’s National Nosocomial 

Infection Surveillance System (Table 1). For CLABSI, VAP, and CAUTI, rates of infections are 

adjusted for the individual hospital’s rate of use of the associated device (catheter or mechanical 

ventilator), and the infection rates are reported as infections per 1,000 device-days. The NNIS 

reports an average CLABSI rate of 4.1-6.1 infections per 1,000 catheter-days in medical-surgical 

ICUs, and even higher rates in other types of ICUs (e.g., burn units, 10.0 per 1,000 catheterdays).14
16

Prevention of CLABSI involves close attention to several factors. Basic rules of infection 

control should be followed, principally involving appropriate hand hygiene.24 Ensuring a sterile 

environment at the time of insertion of the catheter (through use of maximal sterile barrier 

precautions and skin disinfection with chlorhexidine) has been demonstrated to reduce the rates 

of infection in controlled studies,25, 26 and specific insertion practices have been recommended by 

the CDC and other major organizations (Table 2). Appropriate dressing and handling of the 

catheter is clearly important, but no specific strategy has been unequivocally associated with 

reduction of infections (apart from hand hygiene).21 Removal of catheters that are no longer 

necessary is another important step, as increasing duration of catheterization predisposes to 

catheter colonization and subsequent CLABSI.21 Despite extensive research on methods to 

prevent CLABSI, adherence to recommended preventive practices is suboptimal. A recent 

survey found that ICU policies regarding insertion and care of CVCs varied widely, with only 28 

percent requiring maximal sterile barrier use and 36 percent requiring hand hygiene prior to 

catheter insertion.27 Due to the close link between insertion practices and infections, and the 

suboptimal rate of adherence to these practices, the CDC’s Healthcare Associated Infection 

Practices Committee suggested CVC insertion practices as a candidate quality measure for states 

considering public reporting programs.5

 

Ventilator-Associated Pneumonia 

Ventilator-associated pneumonia (VAP) is a common and morbid condition affecting ICU 

patients. The diagnosis of VAP can be difficult. The CDC definition is widely used, but the 

current diagnostic criteria are entirely clinical in nature,28, 29 and a standard for invasive or 

microbiologic diagnosis has yet to be established (Table 1). Nevertheless, VAP is estimated to 

occur in 9-27 percent of patients intubated for more than 48 hours,29 and patients with VAP have 

a higher risk of dying in the ICU than similar patients without VAP, though the magnitude of this 

risk is controversial.30 Patients with VAP remain hospitalized for 7-9 excess days, and costs are 

estimated to be between $12,000 and $40,000 per patient.30

The pathogenesis of VAP is dependent on the duration of mechanical ventilation, 

colonization of the aerodigestive tract with bacteria, aspiration of contaminated secretions, and 

impaired host defenses.31 Prevention of VAP thus focuses on reducing the duration of intubation 

and various strategies to prevent colonization and aspiration. Multiple practice guidelines for 

prevention of VAP have appeared in the last 5 years,28, 31-33 reflecting the rapidly evolving body 

of research on prevention of VAP. 

Catheter-Associated Urinary Tract Infection 

Urinary tract infections associated with urethral catheters (CAUTI) are the most common 

HAI in hospitals in the U.S., and account for approximately 40 percent of all HAIs.34 Over 30 

million urinary catheters are inserted in hospitalized patients in the U.S. each year,35 and in these 

patients, colonization of the catheter resulting in asymptomatic bacteriuria occurs in 

approximately 3-10 percent of patients per day. Once bacteriuria develops, approximately 25 

percent develop symptomatic UTI, and approximately three percent develop bacteremia.11 

Though the attributable morbidity, mortality, and costs of CAUTI are much lower than CLABSI, 

VAP, and SSI on a per-patient basis, due to the frequency of urethral catheterization in 
17

hospitalized patients, asymptomatic bacteriuria and CAUTI often precipitate antibiotic therapy 

and may serve as a reservoir for resistant pathogens.36, 37

Preventive strategies for CAUTI have been evaluated since the 1960s, and (like CVC 

prevention) focus on reducing unnecessary catheter use and reducing colonization of the 

insertion site and catheter apparatus. Use of a closed urinary drainage system was the first 

intervention proven to prevent CAUTI, and these systems are now in standard use.36, 37 Avoiding 

obstruction of the drainage system and using aseptic insertion practices (Table 2) are also 

recommended. While urinary catheters are needed in certain common situations (principally, 

postoperative states, urinary incontinence, need for frequent urinary output monitoring, and 

bladder obstruction),38 evidence shows that catheters are frequently kept in place when no 

indications are present, resulting in up to 50 percent of urinary catheter-days being 

unnecessary.39 This unnecessary catheter use predisposes to colonization and eventual 

symptomatic CAUTI. 

Research Questions 

In this report, we will systematically review the evidence supporting quality improvement 

strategies to reduce the incidence of healthcare-associated infections. We will focus our 

attention on strategies to reduce HAIs in the inpatient setting, specifically addressing prevention 

of surgical site infections, central line-associated bloodstream infection, ventilator associated 

pneumonia, and catheter associated urinary tract infection. Our intent is to identify strategies 

that successfully increase adherence to effective preventive practices for each of these infections 

and reduce infection rates. Our specific research questions are: 

1. Do quality improvement strategies increase adherence to evidence-based preventive 

interventions for healthcare-associated infections? 

a. Which QI strategies increase use of interventions known to prevent surgical site 

infections? 

b. Which QI strategies increase use of interventions known to prevent central venous 

catheter-associated bloodstream infections? 

c. Which QI strategies increase use of interventions known to prevent ventilatorassociated pneumonia? 

d. Which QI strategies increase use of interventions known to prevent urinary 

catheter-associated urinary tract infections? 

e. In each of these areas, are QI strategies associated with reductions in the 

incidence of infections (as well as improving adherence)? 

f. Are QI strategies associated with adverse effects? 

g. Are QI strategies cost-effective? 

2. What are the critical components of effective QI strategies? 

a. What is the evidence for QI strategies targeting the simultaneous implementation 

of multiple preventive interventions (“bundling”)? 

b. What strategies are effective at increasing use of preventive interventions across 

different disease processes? 

3. What are the limitations of current research in this field, and what areas require 

further study?

19

Chapter 2. Methods 

Scope 

This report focuses on healthcare-associated infections contracted in acute care hospitals. 

Specifically, we focused on prevention of four types of infections that collectively account for 

more than 80 percent of all HAIs in hospitals10: surgical site infections (SSI), central lineassociated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and 

catheter-associated urinary tract infection (CAUTI). Prevention of these HAIs has become 

increasingly important not only due to the burden of disease, but because an increasing number 

of states are mandating or considering mandating public reporting of rates of some or all of these 

infections. National organizations such as the Centers for Disease Control and Prevention5 and 

Institute for Healthcare Improvement7

 also recommend focusing on prevention of these HAIs as 

a high-impact method of reducing iatrogenic morbidity and mortality. 

Definitions of QI Terms Used in This Report 

We used quality improvement terminology in accordance with prior volumes of the Closing 

the Quality Gap series, as follows: 

• Quality gap: The difference between health care processes or outcomes observed in 

 practice and those potentially achievable on the basis of current professional knowledge. 

 The difference must be attributable in whole or in part to a deficiency that could be 

 addressed by the health care system. 

• Quality improvement strategy: Any intervention strategy aimed at reducing the quality 

 gap for a group of patients representative of those seen in routine practice. 

• Quality improvement target: The outcome, process or structure that the QI strategy 

 targets, with the goal of reducing the quality gap. 

Classification of Interventions and Quality 

Improvement Strategies 

The intervention(s) used in a study sometimes included more than one QI strategy. Each 

intervention was characterized in terms of the QI strategy (or strategies) employed. 

Interventions containing two or more different QI strategies (as defined by the categorization 

listed below) were considered multifaceted interventions. For example, an intervention using (a) 

audit and feedback and (b) clinician education was defined as a multifaceted intervention, using 

two QI strategies. 

We used a taxonomy of quality improvement strategies as defined in previous volumes of the 

series (Table 3). 
20

Table 3. Quality improvement strategies 

QI strategy Examples 

Provider reminder systems • Reminders in charts for providers 

• Computer-based reminders for providers 

• Computer-based decision support 

Facilitated relay of clinical data to 

providers 

• Transmission of clinical data from outpatient specialty clinic to primary 

care provider by means other than medical record, e.g., phone call or fax 

Audit and feedback • Feedback of performance to individual providers 

• Quality indicators and reports 

• National/state quality report cards 

• Publicly released performance data 

• Benchmarking – provision of outcomes data from top performers for 

comparison with provider’s own data 

Provider education • Workshops and conferences 

• Educational outreach visits (e.g., academic detailing) 

• Distribution of educational materials 

Patient education • Classes 

• Parent and family education 

• Patient pamphlets 

• Intensive education strategies promoting self-management of chronic 

conditions 

Promotion of self-management • Materials and devices to promote self-management 

Patient reminder systems • Postcards or calls to patients 

Organizational change • Case Management, Disease Management 

• Total Quality Management, Cycles of Quality Improvement 

• Multidisciplinary teams 

• Change from paper to computer-based records 

• Increased staffing 

• Skill mix changes 

Financial incentives, regulation, and 

policy 

Provider Directed: 

• Financial incentives based on achievement of performance goals 

• Alternative reimbursement systems (e.g., fee-for-service, capitated 

payments) 

• Licensure requirements 

Patient Directed: 

• Copayments for certain visit types 

• Health insurance premiums, user fees 

Health System Directed: 

• Initiatives by accreditation bodies (e.g., residency work hour limits) 

• Changes in reimbursement schemes (e.g., capitation, prospective 

payment, salaried providers) 

For the purposes of this report, each intervention-control comparison within a study was 

abstracted separately. Thus, if an article reported a three arm trial, in which distinct interventions 

were delivered to participants in two of the arms and the third arm constituted a control group, 

then we considered such a study to contain two trials (the separate comparisons of the two 

intervention arms against the control group). 

Targeted Preventive Interventions 

We defined a “preventive intervention” as a specific infection control practice that has been 

demonstrated to reduce the incidence of a HAI. For each of our target HAIs, a wide variety of 

preventive interventions have been evaluated. We chose to focus on the implementation of 

preventive interventions that are recommended for universal use in target patient populations by 
21

professional societies and governmental organizations. We selected these target preventive 

interventions by reviewing evidence-based HAI prevention guidelines compiled by authorities in 

the field. Specifically, we reviewed the CDC guidelines for prevention of surgical site infection 

(1999),13 prevention of intravascular catheter-related infections (2002),24 prevention of 

healthcare-associated pneumonia (2003),32 and prevention of catheter-associated urinary tract 

infection (1983).40 In order to obtain the most current information on recommended preventive 

interventions, we also reviewed the 2005 Surgical Care Improvement Project41

recommendations, the 2005 American Thoracic Society/Infectious Disease Society of America 

guidelines for the management of patients with healthcare-associated pneumonia,31 the 

recommendations of the Institute for Healthcare Improvement’s “100,000 Lives” campaign, and 

solicited input from our peer review panel. 

We primarily considered for inclusion preventive interventions that received a grade of IA 

(strongly recommended for implementation and supported by well-designed experimental, 

clinical, or epidemiological studies) or IB (strongly recommended for implementation and 

supported by some experimental, clinical, or epidemiological studies and strong theoretical 

rationale) from the CDC prevention guidelines, or an equivalent rating from another professional 

society guideline. We emphasized interventions that were broadly applicable to as large a 

patient population as possible, had a strong evidence base, had a known quality gap (i.e., a 

suboptimal rate of use in practice had been documented), and whose use was potentially 

modifiable through patient-, provider- or system-focused QI strategies. Given this focus, we did 

not address implementation of some strategies whose utility remains controversial (e.g., 

continuous aspiration of subglottic secretions to prevent VAP), and we did not address 

implementation of effective strategies whose use is not under the control of an individual 

provider (e.g., use of antimicrobial-coated central venous or urinary catheters).42, 43 The 

preventive interventions we focused on were determined through consensus, including 

discussion with our group of technical experts and peer reviewers; they are summarized in Table 

2. 

The IHI has recommended “bundles” of preventive interventions for targeting SSI, CLABI, 

and VAP. These bundles are intended to be applied to all eligible patients. Implementation of 

the “bundles” should be measured in an “all-or-none” format, whereby institutions should 

measure and report their adherence to all components of the bundle, and successful 

implementation is defined by adherence to all preventive interventions simultaneously.44 The 

IHI also encourages audit and feedback of the “all-or-none” measurements, as well as specific 

implementation strategies. Our target interventions are similar to those included in the bundles 

advocated in the IHI’s 100,000 Lives campaign, with three exceptions. We did not target 

implementation of perioperative normothermia, as this intervention is not recommended by the 

CDC, and its overall effectiveness remains controversial.45 We also did not target universal 

stress ulcer prophylaxis and deep venous thrombosis (DVT) prophylaxis for ventilated patients. 

Universal stress ulcer prophylaxis has not been shown to reduce VAP (and may in fact increase 

it28), and DVT prophylaxis, while appropriate ICU care, is not directly linked to the prevention 

of VAP. 
22

Inclusion and Exclusion Criteria 

Included studies were required to: 

• Report the effect of an intervention on the incidence of healthcare-associated infection 

(SSI, CLABSI, VAP, or CAUTI), or report the effect of an intervention on adherence to 

evidence-based preventive interventions. 

• Use either an experimental design with a control group (randomized or quasi-randomized 

controlled trial, controlled before-after study) or a quasi-experimental design (interrupted 

time series or simple before-after study). Quasi-experimental studies were required to 

have a clearly defined intervention time period; interrupted time series designs required 

reporting of at least three time points of data before and after the intervention. 

Thus, we included studies that reported either infection rates or process measures (e.g., rate 

of adherence to handwashing protocols). Trials that reported related outcomes, such as costs, 

health services utilization (e.g., length of stay), patient or provider satisfaction with care, or 

adverse events associated with the intervention, were included only if they included data on 

infection rates or process measures. We included studies whose QI strategy targeted 

implementation (or increased use of) any of the target preventive interventions, with one 

exception. A prior systematic review46 has addressed the effectiveness of QI strategies to 

promote appropriate hand hygiene; thus, we did not include studies that reported purely on hand 

hygiene adherence, but did include studies that targeted improving hand hygiene adherence and 

also reported the incidence of one or more of our target HAIs. 

In contrast to previous volumes of this series,47, 48 we expanded our study design inclusion 

criteria to include simple before-after (SBA) studies, quasi-experimental studies in which there 

was no contemporaneous control group and fewer than three data points before and after the 

intervention. We did so after preliminary literature searches revealed a dearth of controlled trials 

in this field. We planned to separately analyze data from controlled trials, when possible. 

Literature Search and Review Process 

To identify studies for possible inclusion, we conducted a systematic search of the 

MEDLINE® database, using a combination of search terms specific to each target HAI. The full 

search strategy is shown in Appendix A*

. We supplemented this search with a search of the 

Cochrane Collaboration’s Effective Practice and Organisation of Care (EPOC) database, which 

includes the results of periodic searches of EMBASE®, CINAHL®, and MEDLINE® as well as 

hand searches of specific journals and article bibliographies.49 The MEDLINE® search was 

completed through January 2006 and the EPOC search through December 2005. We also 

screened the bibliographies of included articles to identify additional references. 

A trained research assistant screened titles and abstracts [Appendix B*

], and a physician 

investigator reviewed all exclusions. Articles that reported the effect of a quality improvement 

strategy on HAI rates or adherence to preventive interventions underwent full-text abstraction 

 

*

 Appendixes cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/hainfgaptp.htm 
23

using a standardized form [Appendix B*

]. Two independent reviewers, including at least one 

physician investigator, performed full-text reviews. The abstraction form recorded information 

on study design, methodological characteristics, quality improvement strategies, and outcomes; 

all disagreements were resolved by consensus.

Outcome Measures 

Included studies reported two types of outcomes: rate of adherence to recommended 

preventive interventions, or rate of healthcare-associated infection. For adherence measures, we 

abstracted the data on adherence to our target preventive interventions (generally reported as the 

percentage of patients who received the intervention), or the adherence to an explicit clinical 

guideline (or “bundle”) for prevention of HAIs. 

For studies reporting infection rates, we abstracted data using the definition of infection as 

defined in the study. The specific subtypes of infection varied slightly for each target HAI: 

• For surgical site infection, we abstracted information on all infections. When possible, 

we planned to analyze infection rates separately for the different classes of SSI, as 

defined by the CDC14: organ/space infections, deep incisional infections, and superficial 

incisional infections. 

• For central line-associated bloodstream infections, we were primarily interested in the 

effects of QI strategies on laboratory-confirmed bloodstream infection (LCBI), and 

separately abstracted information on catheter colonization or exit-site infection. 

• For ventilator-associated pneumonia, we abstracted information on all VAP. 

• For catheter-associated urinary tract infection, we abstracted information separately for 

symptomatic UTI and asymptomatic bacteriuria. 

Measurement Issues Specific to Studies 

of Healthcare-Associated Infections 

In comparison to previous reviews in this Series, unique measurement issues arise when 

evaluating quality improvement studies of efforts to reduce HAIs. The most widely accepted 

diagnostic criteria for HAIs are the NNIS definitions.14, 50 NNIS definitions for SSI, CLABSI, 

and CAUTI are summarized in Table 1. As can be seen, HAIs are not entirely objective 

measurements, unlike outcomes used in previous volumes such as laboratory values or antibiotic 

consumption; also, there are different subtypes of specific HAIs. Studies have demonstrated that 

slight differences in the interpretation of SSI definitions can lead to widely differing infection 

rates51, 52 even when the same subtype of SSI (e.g., only deep incisional infections) are being 

measured. Also, a given study might measure CLABSI using only NNIS-defined laboratory 

confirmed bloodstream infections (LCBI), or also include infections meeting the “clinical sepsis” 

criteria. While these differences in measurement should not affect the internal validity of a 

 

*

 Appendixes cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/hainfgaptp.htm 
24

study, assuming measurement standards remain constant throughout the study, they may limit the 

ability to compare infection rates across studies. 

Measurement of ventilator-associated pneumonia poses additional challenges. Currently, 

there is no easily applicable clinical definition for VAP. Recent research has focused on 

development of a gold standard for diagnosis using invasive methods, but these methods have 

not been widely implemented and remain under evaluation. Thus, studies performed at different 

times may have used slightly different diagnostic criteria, further limiting the comparability of 

infection rates across studies. 

In this review, we will provide the data on incidence of HAIs as measured by the NNIS. 

Given the above limitations, these data are not intended for direct comparison to the incidence 

found by individual studies. However, NNIS data may be useful for identifying studies that have 

an unusually high (or low) baseline incidence of HAI. 

Quality Issues Specific to Studies of 

Healthcare-Associated Infections 

Quasi-experimental or simple before-after (SBA) studies are commonly used in quality 

improvement,53 but are prone to problems that limit establishing causality when determining the 

effect of an intervention. SBA studies are common in the infection control literature.54 Harris55

identified three factors that most often result in alternative explanations in quasi-experimental 

studies of infection control: (1) difficulty in controlling for important confounding variables, (2) 

results that are explained by the statistical principle of regression to the mean, and (3) maturation 

effects, secular trends that can affect either baseline or post-intervention measurements (e.g., 

seasonal variation in infection rates). We recognized that many of our included studies were 

likely to use SBA designs, and thus defined specific quality criteria for these studies to identify 

studies that would be less prone to the above flaws. Our goal was to identify studies where 

(within the limitations of the study design) causality could more reliably be attributed to the 

intervention. We used these criteria to gauge the internal and external validity of study results in 

order to identify studies of the greatest utility for stakeholders. We did not exclude studies based 

on the presence or absence of these quality criteria. The quality criteria are outlined below: 

Factors Affecting the Internal Validity of the Studies 

• Was the intervention performed independent of other QI efforts or other changes? 

Non-randomized studies are inherently limited in their ability to account for confounding 

variables. In the complex hospital environment, many quality improvement efforts are 

generally underway that could affect the care and outcomes of diverse groups of patients. 

Failure to report on cointerventions or other contemporaneous QI measures could result in 

falsely attributing a change in infection rates to the effect of the QI intervention. 

• Did the study report data at more than one time point before and after the intervention? 

Infection control interventions are frequently implemented when infection rates are noted 

to be increasing or to exceed a recognized benchmark.55 Given this context, one would 
25

expect subsequent infection rates to decrease simply on the basis of regression to the mean 

(i.e., even without a specific intervention). If data are presented at a single time point before 

and after the intervention, this expected decrease due to regression to the mean could be 

interpreted as a beneficial effect of the intervention. Use of an interrupted time series design 

can determine if a true intervention effect exists; such a design requires at minimum three 

time points of data before and after the intervention, and use of time series regression models 

or autoregressive integrated moving-average (ARIMA) models for data analysis.49 In the 

absence of such a design, reporting of more than one time point before and after the 

intervention can at least indicate if the pre-intervention infection rate was consistent or 

abruptly increasing, and indicate if the post-intervention rate was sustained. 

• If the study reported infection rates, were process measurements also reported? 

Measuring adherence to process measures (i.e., adherence to the target preventive 

interventions) provides important complementary information to measurement of infection 

rates for several reasons. First, high-quality data links increased adherence to process 

measures to lower infection rates for SSI41 and CLABSI,23 but adherence in general practice 

is known to be suboptimal. Second, as mentioned above, elevated infection rates within a 

given hospital could be due to secular trends, such as outbreaks (e.g., with a genotypically 

distinct resistant bacteria) that may not be directly tied to poor infection control practices. If 

a simple before-after study documents both lower infection rates and improved adherence to 

process measures after an intervention, that provides more (albeit indirect) support for 

concluding that the intervention was truly effective. Finally, process measurements do not 

require adjustment for a patient’s underlying risk of infection.5

 This allows for greater interhospital and inter-study comparability than infection rates alone, and thus reporting of 

process measures can improve the external validity of a study as well as its internal validity. 

For these reasons, the CDC’s Healthcare Infection Control Practices Advisory Committee 

suggested measurement of central venous catheter insertion practices and surgical 

antimicrobial prophylaxis for public reporting, in conjunction with reporting CLABSI and 

SSI rates.5

Factors Affecting the External Validity of the Studies 

As process measures are unambiguous measurements with universal applicability, studies 

reporting process measures were considered to have greater external validity. We posed the 

following questions to assess study external validity for studies reporting infection rates. 

• If the study reported infection rates, did the study use CDC/NNIS methodology for 

measuring infections? 

NNIS definitions for nosocomial infections are the accepted standard in infection control, 

and their accuracy for case finding has been validated.56

• (For CLABSI, VAP, and CAUTI) If the study reported infection rates, were reported rates 

adjusted for device utilization? 
26

HAI rates should be adjusted for potential differences in risk factors.5

 Device-associated 

infections must be adjusted for the rate of use of the device in question, and in the NNIS 

system rates are reported as infections per 1,000 device-days.14 This does not take into 

account many other potential risk factors, but failure to perform this basic level of risk 

stratification would markedly limit the utility of a study’s results. 

• (For SSI) If the study reported infection rates, was surveillance for infections performed 

after hospital discharge?

Depending on the surgical procedure in question, a large proportion of infections may 

occur after discharge from the hospital. In fact, some studies have demonstrated that for 

common surgeries such as knee arthroplasty and abdominal hysterectomy, the majority of 

SSI may not manifest until after discharge.57, 58 Case-finding methods that do not perform 

post-discharge surveillance could thus substantially underestimate the incidence of SSI. 

We used the same criteria as above to address the external validity of controlled studies. For 

internal validity of controlled studies, we used the following criteria, as used in previous volumes 

in the Series: 

• Method of treatment assignment 

– Were study subjects randomized, and if so, was the randomization process described? 

– For non-randomized studies, was the rationale for selection of the comparison group 

explained, and a baseline observation period included (to assess selection bias)? 

• Blinding 

– Were the outcome assessors blinded to treatment group assignment? 

• Statistical analyses 

– Was a unit-of-analysis error present? If so, were appropriate statistical methods used 

for correction? 

Analysis 

In previous volumes in this Series, we have noted marked variation in study populations, 

intervention characteristics, and methodologic features of the included studies, which have 

contributed to statistical heterogeneity.47, 48 We expected to encounter similar issues in this 

review, given the inherent issues in measurement outlined above (and the variation in 

interventions). In addition, we expected to find many simple before-after studies based on our 

preliminary literature searches. Thus, we did not plan to perform quantitative analysis, instead 

planning to summarize studies qualitatively. Using our study quality criteria as a framework, we 

planned to identify studies of relatively stronger internal validity and external validity for more 

detailed discussion. We opted not to use a scoring system for formally determining study 

quality, as the utility of these scores is controversial.59 In general, studies meeting both criteria 

for external validity and two of three criteria for internal validity were considered to be of 

stronger internal validity and external validity, and studies with serious flaws affecting internal 

validity (0 of 3 criteria met) were considered to have poor internal validity. 
27

Chapter 3. Results 

Our search strategy identified a total of 4,847 citations, and one additional unpublished 

citation was identified from our peer review panel (Figure 1). Of these, 434 underwent full-text 

review, and 64 articles met all criteria for inclusion. Of these, three reported data on more than 

one target HAI.60-62 All included studies utilized a single intervention arm. The results are 

summarized according to each target HAI below. Appendix C* lists the excluded studies and the 

reason for exclusion. 

Figure 1. Search results and article triage 

*Includes studies reporting prevention of more than one HAI. 

EPOC: Effective Practice and Organisation of Care; SSI: surgical site infections; CLABSI: central line-associated bloodstream 

infections; VAP: ventilator-associated pneumonia; CAUTI: catheter-associated urinary tract infections. 

 

*

 Appendixes cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/hainfgaptp.htm 

EPOC

166 citations 

Hand search

2 citations 

Total number of potentially 

relevant articles 

4847

MEDLINE 

4678 citations 

Peer reviewers 

1 citation (unpublished) 

4413 exclusions 

No intervention: 1603 

Not quality improvement: 2247 

Excluded topic: 478 

Ineligible study design: 52 

Foreign language: 4 

Other reason: 29 

Stage 1: Article title and abstract 

review 

Total number of articles 

requiring full text review 

434

370 exclusions 

Not an evaluation of a QI 

strategy: 298 

Excluded topic: 16 

Ineligible study design: 18 

No eligible outcomes: 13 

Duplicate publication: 6 

Other reason: 19 

Articles meeting criteria for 

data abstraction 

64

Stage 2: Article full text review 

SSI* 

28 

CLABSI*

19 

VAP*

12 

CAUTI*

10 
28

Surgical Site Infections 

Included Studies: Settings, Goals, and Target Populations 

Our search strategy identified 28 articles that met our inclusion criteria and addressed 

prevention of surgical site infections (Tables 4a-4h). One of these60 reported data on SSI, but its 

intervention primarily targeted VAP; thus, it will be discussed in the VAP section. Most (15) 

studies were conducted in single tertiary care hospitals, but seven were completed in multiple 

hospitals,19, 61, 63-67 and one at a community hospital;68 the hospital type was unclear in five 

studies.69-73 

Many studies took place in a defined location in the hospital, with nine occurring the 

operating room,64, 73-80 six in the intensive care unit,60, 61, 66, 72, 81, 82 and two on the general 

inpatient ward.83, 84 The remainder took place in multiple areas of the hospital. Ten of the 

studies took place in the past decade19, 64, 67, 71-74, 83, 85, 86 but the remainder took place before then 

or did not have a stated time period. Among those reporting follow-up periods, the range was 

one month to four years, with a median of one year. 

Baseline Infection Rates in U.S. and Non-U.S. Studies 

Most of the studies were performed outside of the United States, with 11 in Europe, 

Australia, and New Zealand, 61, 63, 64, 66, 71-73, 75, 80, 84, 86 nine in the United States,19, 69, 70, 76-79, 82, 85

and eight in other countries.60, 65, 67, 68, 74, 81, 83, 87 The NNIS 2004 report published mean surgical 

site infections rates for surgeries performed in the United States that ranged from 0.44 per 100 

cases for low-risk cholecystectomy, 3.45/100 for all coronary artery bypass surgery patients, and 

11.53/100 for high-risk colorectal surgery.14 By comparison, among our included studies, the 

sixteen studies that used surgical site infection rates as an outcome reported a median of 5.4 per 

100 cases and a range of 1.1–24.4 per 100 cases. This range represents the wide range of 

geographic areas, time periods, and types of surgeries among included studies. 

Baseline surgical site infection rates in the United States-based studies were 4-12.4 percent in 

four studies involving QI in cardiac surgery patients70, 79, 82, 85 and 2.3 percent in a large 

multicenter trial.19 In studies from Europe, New Zealand and Australia, the baseline infection 

rates ranged from 5.4 to 13.9 percent in studies with multiple types of surgeries61, 71, 86 and 4.1 

percent in one study of cardiac surgery patients.72 A German study reported a surgical site 

infection rate of 48/1,000 patient-days that cannot be directly compared to the NNIS report.66 

Studies conducted in other countries (including Israel, Brazil, and Guatemala) reported baseline 

surgical site infection rates of 13.5 percent,81 24.4 percent,68 5 percent,60 4.2 percent, 74 and 

0.33/1,000 patient days.87 Overall, studies conducted in Europe, Australia, and New Zealand had 

similar infection rates as those of United States studies, although these rates were higher than 

those reported in the NNIS 2004 report. Studies conducted in all other countries showed much 

higher infection rates than in comparable United States studies, which decreased their 

translatability to United States QI efforts. 
29

Preventive Interventions and Outcomes Measured 

We identified several preventive interventions for review: appropriate provision of 

perioperative antibiotics (including appropriate timing, selection and duration of antibiotics), 

hand hygiene, perioperative glycemic control, and avoidance of preoperative shaving. Eleven 

studies targeted more than one process measure, including at least one of the above.19, 61, 63, 66, 68, 

69, 72-75, 82 Promotion of the appropriate use of perioperative antibiotics was used in 23 of the 28 

studies;19, 61, 63-69, 72-80, 82-86 in ten of these, other preventive interventions were advocated as 

well.19, 61, 63, 66, 68, 69, 72-75 Sixteen of the 23 studies targeting perioperative antibiotics reported 

data on appropriate antibiotic use before and after the intervention; the other seven studies 

reported only SSI rates. Hand hygiene promotion was used in seven of the studies,60, 66, 69, 72, 74, 

81, 87 often as part a comprehensive infection control program.66, 69, 72, 74 Four studies targeted 

improved perioperative glycemic control19, 66, 74, 85 and eight studies promoted avoidance of 

shaving at the operative site19, 61, 66, 69, 72, 74, 82, 85 as part of a comprehensive infection control 

program, but no studies used either intervention alone. Overall, both U.S. and non-U.S. studies 

used similar preventive interventions. 

Ten studies used surgical site infection rate as the primary outcome,61, 66, 68, 70-72, 74, 79, 81, 82

eight used process measures as primary outcomes, 63-65, 73, 77, 78, 80, 84 and eight used surgical site 

infection rate and at least one included process measure as a primary or secondary outcome.19, 60, 

67, 69, 76, 85-87 We did not attempt quantitative synthesis of the results because of the heterogeneity 

of outcomes, preventive methods, and baseline surgical site infection rates. 

Quality Improvement Strategies 

Included studies directed audit and feedback methods, educational interventions or clinical 

reminders at providers (Tables 4a-4h). Physicians were specifically targeted in ten studies,63-65, 

71, 73, 75-78, 80 nurses in one,69 and both physicians and nurses in seven studies;60, 61, 66, 68, 79, 84, 86 the 

remainder targeted all clinical staff.67, 70, 72, 74, 81-83, 85, 87 Clinical reminder systems were explicitly 

used in five studies targeting appropriate antibiotic use; two used a computerized physician order 

entry (CPOE) system,78, 79 and three others used a preprinted reminder sticker or forms.64, 76, 83 

Every study that did not use a clinical reminder system used some type of educational program. 

Seven studies employed consensus-building sessions,19, 60, 64, 65, 70, 75, 83 and the remaining studies 

distributed information using lectures or written materials. One study used academic 

counterdetailing.63 Fourteen studies explicitly used audit and feedback19, 61, 66, 69-73, 75, 82-84, 86, 87 as 

a means of directly decreasing infection rates or of promoting specific interventions (see above). 

Fifteen used organizational change strategies such as creation of multidisciplinary teams or 

adding additional staff to existing teams to monitor and promote changes in infection control 

practices, along with either audit and feedback or consensus building sessions.19, 61, 63, 67, 69, 71, 72, 

77, 80-86

Methodological Quality of Included Studies 

The methodological quality of studies was generally poor because 22 of 28 used a quasiexperimental simple before-after design (Tables 4a-4h). We identified two interrupted time 

series,67, 86 three controlled before-after studies,63, 64, 66 and one randomized control trial (RCT) 
30

(Tables 4a, 4b, 4f).79 Most of the simple before-after studies had limited internal validity (Table 

5). Five simple before-after studies reported data on more than one time point before and after 

the intervention; 60, 61, 69, 74, 85 most (14/23) reported at least one process measurement.19, 60, 65, 69, 

73, 75-78, 80, 83-85, 87 No study clearly stated that the intervention was conducted independent of any 

other quality improvement effort. Three simple before-after studies met two criteria for internal 

validity.60, 69, 85 Despite difficulties with internal validity, some studies exhibited good external 

validity as they used standard NNIS/CDC methods to track infections and performed postdischarge surveillance.74, 75, 82 Among those studies reporting surgical site infection rates, most 

reported an overall infection rate, but two studies separately reported superficial incisional, deep 

incisional, and organ/space infection rates.61, 82 

Given the generally poor methodological quality of the results and the heterogeneity of the 

methods used, we will summarize the results according to their study design, internal and 

external validity, and give less detail on lower quality studies. We further divided the studies 

into the 16 studies that reported compliance with appropriate antibiotic prophylaxis as an 

outcome measure,19, 61, 63-65, 67, 73, 75-80, 83, 84, 86 and those that reported other outcome measures, 

including the surgical site infection rate. 

Studies Addressing Use of Appropriate Antibiotic Prophylaxis 

Controlled Trials. One controlled study was conducted in six pairs of matched hospitals (four 

teaching, two suburban, and six rural hospitals), and focused on improving appropriateness of 

perioperative antibiotic timing and duration (Table 4a).63 The educational effort centered on 

academic counterdetailing, a process in which pharmaceutical marketing techniques are used to 

promote academic goals (suggest moving this definition up to where the term is first used). 

Investigators used promotional gifts, posters, lectures, videos, and targeted letters to inform the 

physician staff about appropriate perioperative antibiotic use. The study showed improvement in 

appropriate duration (absolute improvement of 20.0 percent, p=0.04) and in appropriate timing 

(absolute improvement of 13.0 percent, p=0.12). The study employed a crossover design, and 

similar results were seen in the second (crossover) phase of the study. This improvement 

reverted to baseline after the QI effort was stopped during the final phase of the study. The 

study’s generalizability to current U.S. hospital practices is moderate despite the multicenter 

design because the study took place in Australia 20 years ago. 
31

Table 4a. Articles addressing prevention of surgical site infections (studies addressing use of appropriate 

antibiotic prophylaxis): controlled studies 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement 

intervention

Results 

Landgren 

198863 Australia 

Multiple 

hospitals 

of 

different 

types 

1985-

1986 

2 years Appropriate 

use of 

perioperative 

antibiotics 

QI strategies: Clinician 

education, audit and feedback, 

clinician reminder 

Counter-detailing program 

designed to counter efforts of 

pharmaceutical 

representatives and align 

behavior more closely with 

antibiotic guidelines booklet, 

widespread in Victoria, 

Australia. 

1) All surgeons, anesthetists, 

and residents received pen, 

notepads similar to that of 

drug companies, each carrying 

rational prescribing message. 

2) 2 posters focused on proper 

antibiotic use, and 1 offering 

positive reinforcement. 

3) Audit of results 

4) lecture organized for 

surgical staff, discussing 

results of audit. 

5) 10 minute satirical 

videotape was produced 

specifically for staff, mocking 

drug reps, surgeons, RNs, 

microbiologists: aimed to 

stimulate discussion. 

6) Academic representative 

met with select number of 

surgeons, especially those 

unable to attend. 

Adherence to appropriate 

timing of perioperative 

antibiotics: 

Net effect size (change in 

intervention – change in 

control) = 20%; p=0.04 

Adherence to 

administering perioperative 

antibiotics for the 

appropriate duration: 

Net effect size (change in 

intervention – change in 

control) = 14%; p=NS 
32

Table 4a. Articles addressing prevention of surgical site infections (studies addressing use of appropriate antibiotic 

prophylaxis): controlled studies (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement 

intervention

Results 

Ritchie 

200464 United 

States 

Multiple 

hospitals 

of 

different 

types 

9/1999 1 

month 

Appropriate 

use of 

perioperative 

antibiotics 

QI strategies: Clinician 

education, clinician reminder 

Investigators used a 

retrospective audit to 

characterize use of antibiotics 

in pre-intervention period. 

After a consensus building 

session with orthopedic 

surgeons, anesthetists and 

investigators, all agreed that 

they would use preprinted 

sticker placed to remind 

anesthesiologist and surgeon 

to use cefazolin at induction, 

and for no more than 2 doses 

after surgery. 

Adherence to appropriate timing 

of perioperative antibiotics: 

Net change in adherence 

(change in intervention group – 

change in control group): 15% 

p value not supplied 

Adherence to administering 

perioperative antibiotics for the 

appropriate duration: 

Net change in adherence 

(change in intervention group – 

change in control group): 56% 

p value not supplied 

Zanetti 

200379 United 

States 

Tertiary 

care or 

university 

hospital 

Not 

specified 

1 

month 

Appropriate 

use of 

perioperative 

antibiotics 

QI strategies: Clinician 

reminder 

Computer-generated 

automatic alert for redosing 

prophylactic antibiotics in 

prolonged cardiac surgery. 

Infection rates: 

Net change in infection rate 

(change in intervention group – 

change in control group) = 2.0%; 

p=NS 

Appropriate redosing of 

antibiotics: 

Net change in frequency of 

appropriate redosing (change in 

intervention group – change in 

control group) = 28%; p<0.01 

A second controlled study was also directed at providers: a preprinted sticker was placed to 

remind providers to limit the duration of prophylactic antibiotics (cefazolin) to three doses total 

(Table 4a).64 The policy in the control group was usual care. In the intervention hospital, 

appropriate cefazolin use rose from 29 percent to 74 percent (p<0.001). However, the study’s 

internal validity is moderate. The authors failed to explain how the control hospital was chosen; 

in addition, the improvement in cefazolin use occurred in all intervention hospital patients 

regardless of whether the sticker was used. This suggests a possible Hawthorne effect (i.e., 

physicians changed their behavior due to awareness that a study was ongoing) or spillover of the 

educational effect of the sticker to other clinical situations. 

A randomized controlled trial took place in a major teaching hospital that had a preexisting 

integrated computerized physician order entry system (Table 4a).79 Patients were randomized to 

receive a computerized reminder if prophylactic antibiotics needed redosing during a long 

operation. The study reported significantly more frequent intraoperative redosing in the 

intervention group (68 percent vs. 40 percent, p<0.001) though no statistically significant 

differences in the secondary outcome (surgical site infection rate was four percent in the treatment 

group vs. six percent in the control group, p=0.42). The study was likely underpowered to detect 

difference in infection rates. The study was a well-designed RCT, but has only moderate 
33

applicability because the study hospital’s provider characteristics (which include familiarity with 

CPOE) are uncommon. 

Interrupted Time Series Studies. One study86 was conducted in a diverse group of 13 Dutch 

hospitals (both teaching and non-teaching) that were already participating in a national 

surveillance network (Table 4b). A supervising committee received surveillance data from the 

individual hospitals, and supplied feedback to the hospital based on process and outcome 

measures. They also organized educational meetings for both nurses and physicians, 

emphasizing guideline adherence and appropriate use of prophylactic antibiotics. The precise 

content of both the feedback and the educational content were not discussed. The study 

exhibited good internal and external validity. It was a prospectively designed study where the 

pre-intervention baseline was established in multiple hospitals over one year. In addition, the 

committee collected data on several process measurements as well as on surgical site infections. 

Given that these hospitals were part of a surveillance network, it seems likely that other QI 

interventions were ongoing but it is unclear whether these would have affected surgical site 

infections. The distribution of surgeries remained stable between hospitals, but the proportion of 

orthopedic and gynecological surgery increased after the intervention; the authors adjusted for 

this change in their comparison. The study’s results are translatable to other settings because the 

investigators followed CDC recommendations for surgical site infection post-discharge 

surveillance and standard prophylactic antibiotic protocols. Results revealed statistically 

significant increases in appropriate duration (55.8 percent to 68.6 percent), selection (4.9 percent 

to 62.5 percent) and timing of antibiotic administration (49.5 percent to 60.6 percent). The study 

showed a non-significant trend toward reduced surgical site infections: 5.4 percent preintervention and 4.6 percent post-intervention. 

Another study67 used continuous quality improvement (CQI) methodology to target 

postoperative infections among women undergoing cesarean section at two maternity hospitals in 

Colombia (Table 4b). At each hospital, multidisciplinary teams were formed that underwent 

training in CQI methods by outside facilitators; these teams then researched the problem of SSI 

and formulated a structured approach using multiple cycles of interventions and measurement. 

The intervention focused on streamlining the process of ordering and administering perioperative 

antibiotics, along with feedback of infection rates to hospital administrators. The study’s internal 

and external validity were excellent, as the investigators collected at multiple time points, 

performed appropriate ITS statistical analysis, measured both process measures (use of 

perioperative antibiotic prophylaxis and appropriate timing of prophylactic antibiotics) and 

infection rates, and used CDC/NNIS measurement standards. The intervention achieved 

statistically significant improvements in administration of antibiotics (i.e., whether or not 

antibiotics were given at all) and appropriate timing of antibiotics at both hospitals; SSI rates 

were significantly reduced as well. 
34

Table 4b. Articles addressing prevention of surgical site infections (studies addressing use of appropriate 

antibiotic prophylaxis): interrupted time series 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement 

intervention

Results 

Weinberg, 

200167 Colombia 

Two 

academic 

maternity 

hospitals 

1996-

1998 

Hospital 

A: 12 

months 

Hospital 

B: 21 

months 

Appropriate 

use of 

perioperative 

antibiotics 

Decreasing 

use of 

preoperative 

shaving of the 

operative site 

QI strategies: Audit and 

feedback, organizational change 

A CQI intervention was 

performed targeting surgical site 

infections in women undergoing 

cesarean section at 2 hospitals 

in Bogota, Colombia. At both 

hospitals, multidisciplinary teams 

were formed consisting of an 

obstetrician, resident, nurse, 

pharmacist, and administrator. 

The teams reviewed the 

literature to identify risk factors 

for SSI. The teams underwent 

training in CQI methods by 

outside facilitators, then used 

PDSA methods to identify the 

problem and formulate an 

approach. SSI rates were fed 

back to administrators and (at 

one hospital) to individual 

physicians. 

Infection rate prior to 

intervention: Hospital A, 

10.5%; Hospital B, 6.1% 

Infection rate after 

intervention: Hospital A, 

0%; Hospital B, 4.4%; 

p<0.001 for hospital A, 

p=0.042 for hospital B 

Compliance with 

appropriate timing of 

antibiotic prophylaxis: 

Compliance before 

intervention: hospital A, 

24%; hospital B, 70% 

Compliance after 

intervention: hospital A, 

96%; hospital B, 96%; 

p<0.001 for both

Van 

Kasteren 

200586

Netherlan

ds 

Tertiary 

care or 

university 

hospital 

7/2001 

– 

10/2002 

16 

months 

Appropriate 

use of 

perioperative 

antibiotics 

QI strategies: Clinician 

education, audit and feedback, 

clinician reminder 

Implementation of a national 

guideline for surgical 

antimicrobial prophylaxis at 13 

Dutch hospitals. The guideline 

recommends single-dose 

prophylaxis with a cephalosporin 

(plus metronidazole if indicated) 

to be administered within 30 

minutes before incision. Each 

hospital received feedback on 

their baseline compliance rate to 

the guideline. The study group 

formulated recommendations for 

improving adherence at each 

hospital, and discussed them 

with physicians and nurses. 

Additional educational meetings 

were held. 

Infection rate prior to 

intervention: 5.4% 

Infection rate after 

intervention: 4.5%; 

p=NS 

Adherence to 

administering 

perioperative antibiotics 

for the appropriate 

duration: 

before intervention: 

44.2% 

after intervention: 

31.4%; p<0.01 

Adherence to 

appropriate selection of 

antibiotics: 

before intervention: 

3.9% 

after intervention: 

63.5%; p<0.01 

Adherence to 

appropriate timing of 

perioperative antibiotics: 

before intervention: 

49.5% 

after intervention: 

61.6%; p<0.01 
35

Before-After Studies With Good Internal and External Validity. A large study was 

conducted in Italy between 1987 and 1989 in which a group of 12 hospitals convened a series of 

meetings with surgeons and nurses in each of the participating wards to discuss nosocomial 

infection rates and promote best practices (Table 4c).61 Targeted practices included avoiding 

preoperative shaving, using appropriate, short-term antibiotic prophylaxis, limiting invasive 

procedures and drains, implementing respiratory exercises, and using optimal disinfection 

procedures. Several time points were measured, and multiple hospitals were used, strengthening 

both internal and external validity. The authors reported small but statistically significant 

improvements for all process measures, including a drop in prolonged antibiotic prophylaxis 

(36.9 percent to 27.2 percent, p<0.001). The surgical site infection rate was unchanged (7.8/100 

to 6.7/100 cases, p>0.05); in addition, the authors reported non-significant changes in both the 

superficial infection rate (6.7/100 to 5.7/100 cases) and the deep infection rate (1.9/100 to 

1.05/100 cases) but they did not state which definitions were used for these outcomes. 

Table 4c. Articles addressing prevention of surgical site infections (studies addressing use of appropriate 

antibiotic prophylaxis): before-after studies with good methodologic quality 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results 

*Greco 

199161 Italy 

Multiple 

hospitals 

of different 

types 

12/1988 

– 

6/1989 

19 

months 

Appropriate 

use of 

perioperative 

antibiotics 

Decreasing use 

of preoperative 

shaving of the 

operative site 

Audit and 

feedback of 

infection rates 

to hospitals or 

individual 

clinicians 

QI strategies: Clinician education, 

audit and feedback, clinician reminder 

Series of meetings with surgeons and 

nurses from each of participating 

wards. Data on infection incidence and 

practices were discussed and best 

practices reviewed including: 

appropriate use of perioperative 

antibiotics (pre-operative, limited 

duration, appropriate selection), 

avoidance of preoperative shaving, 

closed drainage of urinary catheters 

and surgical drains, implementation of 

respiratory exercises, use of hygienic 

measures for urinary catheters. 

Infection rate prior 

to intervention: 

7.8% of patients 

Infection rate after 

intervention: 6.2% 

of patients 

p=NS 

* This study addresses prevention of surgical site infections and catheter-associated urinary tract infections. 

Before-After Studies With Moderate Internal and External Validity. A large multi-hospital 

study was conducted to examine implementation of several process measures, including 

appropriate use of prophylactic antibiotics, prevention of hyperglycemia, normothermia, 

avoidance of shaving, and optimization of oxygen tension (Table 4d).19 Fifty-six hospitals 

participated in the effort, where teams of clinical leaders from each hospital attended learning 

sessions. They shared strategies and implemented them at their respective hospitals, but details 

regarding local implementation strategies were not available. Outcomes were analyzed by 

hospital, as patient level data was unavailable. Internal validity was strengthened by the 

reporting of outcomes for process measures and for surgical site infection. The surgical site 

infection rate showed a non-significant improvement from 2.3 per 100 cases to 1.7 per 100 cases. 

The improved adherence to all preventive interventions was statistically significant, including 

timing 
36

Table 4d. Articles addressing prevention of surgical site infections (studies addressing use of appropriate 

antibiotic prophylaxis): before-after studies with moderate methodologic quality 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement 

intervention

Results 

Dellinger 

200519 United 

States 

Multiple 

hospitals 

of 

different 

types 

4/2002-

2/2003 

11 

months 

Appropriate 

use of 

perioperative 

antibiotics 

Decreasing 

use of 

preoperative 

shaving of the 

operative site 

Improving 

perioperative 

glucose 

control 

QI Strategies: Clinician 

education, audit and 

feedback, clinician reminder 

Collaboration among 56 

hospitals to study 

implementation of 1 or more 

quality initiatives. Each facility 

created team of "clinical 

champion" - surgeon or 

anesthesiologist - along with 

day-to-day coordinators. 

Learning sessions performed 

every 4 months. 

Subsequently, information 

was brought back to individual 

facilities. Exact means of 

diffusion of information for 

specific measures were not 

stated. 

Infection rate prior to 

intervention: 2.28% of cases 

Infection rate after 

intervention: 1.65% of cases; 

p=NS 

Adherence to administering 

perioperative antibiotics for 

the appropriate duration: 

before intervention: 72% 

after intervention: 92%; 

p<0.01 

Adherence to appropriate 

selection of perioperative 

antibiotics: 

prior to intervention: 90% 

after intervention: 95%; 

p<0.01 

Adherence to protocols for 

perioperative shaving of the 

surgical site: 

prior to intervention: 59% 

after intervention: 95%; 

p<0.01 

Adherence to protocols for 

perioperative normothermia: 

prior to intervention: 57% 

after intervention: 74%; 

p<0.01 

Adherence to protocols for 

perioperative glucose control: 

prior to intervention: 46% 

after intervention: 54%; 

p<0.01 

Larsen 

198976 United 

States 

Tertiary 

care or 

university 

hospital 

6/1986 

– 

11/1986 

6 

months 

Appropriate 

use of 

perioperative 

antibiotics 

QI Strategies: Audit and 

feedback, clinician reminder 

Authors used pre-existing 

information system (Health 

Evaluation through Logical 

Processing -HELP) to monitor 

patients. Subsequently, 

computer decision analysis 

tool implemented to prepare 

reminder stickers to be placed 

in chart. Reminder stickers 

focused on provision of 

appropriate antibiotic 

prophylaxis. 

Infection rate prior to 

intervention: 1.1% of cases 

Infection rate after 

intervention: 0.7% of cases 

p value not supplied 

Adherence to appropriate 

timing of perioperative 

antibiotics: 

before intervention: 40% 

after intervention: 58% 

p<0.01 
37

of antibiotics within one hour (72 percent to 92 percent), appropriate selection of antibiotics (90 

percent to 95 percent), and discontinuation of antibiotics within 24 hours (67 percent to 85 

percent). However, the authors could not adjust for differences in patient or provider 

characteristics as they only had access to hospital level data, and they did not report data on 

multiple time points prior to the implementation. Mitigating these concerns, the broad range of 

participating hospitals gave the data good external validity and reduces the possibility that the 

improvement represented regression to the mean. 

One study implemented a computerized reminder using a preexisting computer decision 

analysis system to improve antibiotic prophylaxis (Table 4d).76 The study was conducted 

prospectively, with baseline prescribing habits established during the first year and the 

intervention implemented during the second year. Computer generated reminders were placed in 

the chart during the intervention period. Antibiotics were given within two hours of incision in 

40 percent of the sample prior to the intervention, and 58 percent of the sample after the 

intervention (p<0.001 for the difference). The infection rate declined from 1.8 percent to 0.9 

percent, but the external validity of this outcome is diminished because the authors did not use 

CDC criteria to diagnose infections and did not conduct post-discharge surveillance. 

Before-After Studies With Poor Internal and External Validity. Eight studies in this 

category met our inclusion criteria but had methodological flaws that seriously limited their 

internal external validity (Table 4e).65, 73, 75, 77, 78, 80, 83, 84 An Italian study examined the impact of 

a preoperative antibiotic prophylaxis protocol, but included one time point before and after the 

intervention and gave few details as to the nature of the QI intervention.75 In a 1988 study, a 

multidisciplinary program was used to promote use of single dose cefazolin in obstetrical and 

gynecological surgical procedures.77 However, other QI interventions were ongoing, making the 

results less reliable; the authors also reported several results where the numbers were 

inconsistent. A study using a CPOE system to remind providers to redose prophylactic 

antibiotics during long surgeries showed a great improvement after institution of the protocol (20 

percent to 58 percent)78 but only reported data immediately before and after the intervention. A 

French study examined the effect of local guideline development on antibiotic usage but reported 

data in terms of a composite outcome (using indication, selection, dosage, timing, dosing 

interval, and duration), which limits our ability to discern the effect of the QI strategy.73 In 

addition, only two time points were analyzed, which limits internal validity. A Brazilian hospital 

program used preprinted order forms to promote appropriate use of surgical antibiotic 

prophylaxis and demonstrated a statistically significant improvement in this process 

measurement; however, only two time points were analyzed.83

Two studies (conducted at the same hospitals in the Netherlands) measured compliance with 

guidelines regarding the selection and duration of antibiotics84 or timing of prophylactic 

antibiotics80 before and after an intervention (Table 4e). However, the intervention and preintervention measurement periods were two years apart and the intervention took place over one 

year in between measurements, making it difficult to infer causality in either study. Another 

study measured the effect of having control of antimicrobial drugs by an infectious disease 

specialist.65 The average prophylactic drug course in the study was four days (range 1-34 days), 

limiting applicability to current practice. 
38

Table 4e. Articles addressing prevention of surgical site infections (studies addressing use of appropriate 

antibiotic prophylaxis): before-after studies with poor methodologic quality 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement 

intervention

Results 

Brusaferro 

200175 Italy 

Tertiary 

care or 

university 

hospital 

12/1998 6 

months 

Appropriate 

use of 

perioperative 

antibiotics 

QI Strategies: Clinician 

education, audit and feedback 

A protocol for perioperative 

antibiotic prophylaxis was 

developed by a group 

consisting of a microbiologist, 

chemist, anesthetist, clinical 

pharmacologist and three 

surgeons. Compliance with 

the protocol was measured 

before and after the 

intervention. Follow-up focus 

groups were conducted with 

the group and the surgical 

units after the data were 

collected. 

Compliance to guideline 

for perioperative 

antibiotic prescribing: 

before intervention: 

4.3% 

after intervention: 17.4% 

p<0.01 

Smith 

198877 United 

States 

Tertiary 

care or 

university 

hospital 

5/1988 – 

11/1988 

16 

months 

Appropriate 

use of 

perioperative 

antibiotics 

QI Strategies: Clinician 

education, clinician reminder 

1) Direct education programs 

(in-service) were presented to 

anesthesia and OR staff. 

2) Change in OR drug stocks 

to change provider use 

3) In-service education by 

director of obstetrics and 

gynecology directed at specific 

attendings 

4) Eventually hospital required 

that formal Infectious Diseases 

consultation and approval for 

all disfavored antibiotics. 

Compliance with using 

single dose cefazolin as 

preoperative antibiotic 

prophylaxis, percent 

compliance before 

intervention: 0% 

after intervention: 42.8% 

p value not supplied 

St. 

Jacques 

200578

United 

States 

Tertiary 

care or 

university 

hospital 

Not 

specified 

1 month Appropriate 

use of 

perioperative 

antibiotics 

QI Strategies: Clinician 

reminder 

Used computer reminder 

system to assist in 

intraoperative redosing of 

prophylactic antibiotics. 

Adherence to 

appropriate timing of 

perioperative antibiotics: 

before intervention: 20% 

after intervention: 57% 

p<0.01 
39

Table 4e. Articles addressing prevention of surgical site infections (studies addressing use of appropriate antibiotic 

prophylaxis): before-after studies with poor methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length of 

follow-up 

Preventive 

Interventions 

Quality improvement 

intervention

Results 

Talon 

200173 France 

Hospital 

type not 

specified 

6/1998 -

7/1998 

2 months Appropriate 

use of 

perioperative 

antibiotics 

Audit and 

feedback of 

infection rates 

to hospitals or 

individual 

clinicians 

QI Strategies: Clinician 

education, audit and 

feedback 

A survey of antibiotic 

prescribing practices was 

performed and used to 

develop local guidelines for 

antimicrobial prophylaxis 

by a multidisciplinary team. 

Diffusion of guidelines to 

all surgeons and 

anesthetists, as well as 

display of guidelines. 

Adherence to appropriate 

timing of perioperative 

antibiotics: 

before intervention: 89% 

after intervention: 98% 

Adherence to administering 

perioperative antibiotics for 

the appropriate duration: 

before intervention: 76% 

after intervention: 94% 

Adherence to appropriate 

selection of perioperative 

antibiotics: 

before intervention: 74% 

after intervention: 96% 

Overall percentage of 

inappropriate prescriptions 

(timing, duration, and 

selection): 

Before intervention: 69% 

After intervention: 18%; 

p=0.01 

Prado 

200283 Brazil 

Tertiary 

care or 

university 

hospital 

10/1999 1 month Appropriate 

use of 

perioperative 

antibiotics 

QI Strategies: Clinician 

education, clinician 

reminder 

Multiple interventions were 

instituted: 

1) Created a 

multidisciplinary leadership 

team with representatives 

from surgical, infection 

control, pharmacy, and 

hospital epidemiology and 

quality-improvement 

departments. 

2) Creation of a preprinted 

perioperative antibiotic 

prophylaxis form indicating 

only type of surgery. 

3) Review of form by all 

parties involved (RNS, 

MDs) 

4) initiation of perioperative 

antibiotic prophylaxis 

protocol. 

Infection rate prior to 

intervention: 4.1% 

Infection rate after 

intervention: 4.2%; p=NS 

Adherence to administering 

perioperative antibiotics for 

the appropriate duration: 

before intervention: 21.4% 

after intervention: 95.8%; 

p<0.01 

Adherence to appropriate 

selection of perioperative 

antibiotics: 

before intervention: 74.5% 

after intervention: 97.2%; 

p<0.01 
40

Table 4e. Articles addressing prevention of surgical site infections (studies addressing use of appropriate antibiotic 

prophylaxis): before-after studies with poor methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length of 

follow-up 

Preventive 

Interventions 

Quality improvement 

intervention

Results 

Gyssens 

199680 Netherlan

ds 

Tertiary 

care or 

university 

hospital 

1990 -

1992 

14 months Appropriate 

use of 

perioperative 

antibiotics 

QI Strategies: Clinician 

education, clinician 

reminder 

A guideline for standard 

surgical antimicrobial 

prophylaxis was 

introduced, which called 

for standard single-dose 

prophylaxis with a 

cephalosporin to be 

delivered within 1 hour 

prior to surgical incision. 

The guideline was 

introduced after a 

preintervention period in 

which the rates of 

appropriate antimicrobial 

prophylaxis were 

measured and reported to 

the department 

chairpersons. The protocol 

was developed in concert 

with the surgeons. The 

guideline was presented to 

the surgical department 

and junior pharmacists 

introduced it to the nursing 

staff (no other details on 

the implementation 

process are provided.) 

Adherence to administering 

perioperative antibiotics for 

the appropriate duration: 

before intervention: 21% 

after intervention: 85% 

p<0.01 

Adherence to appropriate 

timing of perioperative 

antibiotics: 

before intervention: 42% 

after intervention: 73% 

p<0.01 

Gyssens 

199684 Netherlan

ds 

Tertiary 

care or 

university 

hospital 

1 month Not 

specified 

Appropriate 

use of 

perioperative 

antibiotics 

QI Strategies: Clinician 

education, audit and 

feedback, clinician 

reminder 

The principal goal was to 

universally have a singledose of cephazolin at 

incision. 

Recommendations were 

adapted into new protocols 

and presentations were 

held on these new 

protocols. Junior 

pharmacists organized 

briefings for nurses and 

prophylaxis guidelines 

were displayed in the 

wards and operating 

rooms. Pharmacy techs 

discussed protocol 

violations with prescribers 

and nurses on their twice 

weekly visits to wards. 

Adherence to administering 

perioperative antibiotics for 

the appropriate duration: 

before intervention: 79% 

after intervention: 92% 

p<0.01 
41

Table 4e. Articles addressing prevention of surgical site infections (studies addressing use of appropriate antibiotic 

prophylaxis): before-after studies with poor methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length of 

follow-up 

Preventive 

Interventions 

Quality improvement 

intervention

Results 

Shapiro 

198165 Israel 

Multiple 

hospitals 

of 

different 

types 

Not 

specified 

Not 

specified 

Appropriate 

use of 

perioperative 

antibiotics 

QI Strategies: Clinician 

education 

Introduction of a protocol 

involving changing the 

perioperative antibiotics 

used previously, initiating 

prophylaxis shortly before 

the operation, and 

encouraged the 

curtailment of prophylactic 

administration of 

antimicrobial drugs in the 

early postoperative period. 

Adherence to administering 

perioperative antibiotics for 

the appropriate duration: 

before intervention: 39% 

after intervention: 97% 

p value not supplied 

Studies Not Using Appropriate Antibiotic Prophylaxis as an Outcome 

 

Controlled Trials. One controlled before-after study was conducted in multiple hospitals 

(including several teaching hospitals) and evaluated if a quality management project could 

reduce all types of nosocomial infections (Table 4f).66 The investigators used ‘quality circles’ 

which consisted of a committee with at least one physician and one nurse representative from 

each study hospital. These committees actively reviewed infection control practices and 

surveillance data from each institution and guided modification of infection control practices. 

Surgical site infections declined from 2.2/100 cases to 1.6/100 cases (not statistically significant) 

and overall nosocomial infections declined from 7.5/100 cases to 5.3 cases/100 cases (a 

significant decrease). Several factors undermine the internal validity of the study. The control 

group was not randomly assigned, but instead consisted of those hospitals that declined to 

participate in the quality management project. In addition, the surgical site infection rate (but not 

the overall nosocomial infection rate) reverted back to baseline by the end of the study. The QI 

strategy (‘quality circles’) did not have a clear mechanism for improvement so it is difficult to 

infer causality between the intervention and the primary outcome, especially considering that all 

of the hospitals were interested in quality improvement and may have had concurrent QI 

projects. 
42

Table 4f. Articles addressing prevention of surgical site infections (studies not using appropriate antibiotic 

prophylaxis as an outcome): controlled studies 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results 

Gastmeier 

200266 Germany 

Multiple 

hospitals 

of 

different 

types 

10 

months 

2 years Hand hygiene 

Appropriate use 

of perioperative 

antibiotics 

Decreasing use 

of preoperative 

shaving of the 

operative site 

Improving 

perioperative 

glucose control 

QI strategies: Clinician education, audit and 

feedback 

Intervention hospitals introduced quality 

circles and surveillance activities. The 

quality circles consisted of at least 1 

physician and 1 nurse from the surgical unit 

and ICU, and infection control personnel. 

The quality circles were structured groups 

that used continuous quality improvement 

(CQI) methodology to decide on a problem 

focus, reach a consensus on solving a 

given problem, and execute the solution. 

Each QC focused on hand hygiene, but 

otherwise each intervention hospital 

individualized their focus. Thus, each 

hospital focused on different aspects of SSI, 

CAUTI or CLABSI prevention; the specific 

preventive interventions targeted appear to 

vary between hospitals, but generally 

belonged to CDC category I. After a 10-

month period in which the quality circles 

were set up, outcomes were measured, and 

subsequently ongoing surveillance was 

performed by infection control nurses 

according to NNIS protocols. Outcomes 

were measured again after another 10 

months.

Infection rate 

prior to 

intervention: 

2.6% of 

cases 

Infection rate 

after 

intervention: 

2.0 % of 

cases 

p=NS 

Before-After Studies With Moderate Internal and External Validity. A study conducted in 

Israel measured infection rates for permanent cardiac antiarrhythmic devices before and after the 

implementation of comprehensive infection control program (Table 4g).74 The investigators 

combined education on antiseptic techniques, avoidance of preoperative shaving, preoperative 

antiseptic showers, optimization of perioperative hyperglycemia, improvement in ventilation, 

and promotion of perioperative prophylaxis. The authors noted a decrease in the rate of 

infections from 4.2 percent in the immediate pre-intervention period to 0 percent. However, the 

rate of SSI had been 0.5 percent for three years prior to the increase to 4.2 percent, so the 

decrease could simply represent regression to the mean. 

Two studies in this category investigated quality improvement in cardiac surgery (Table 

4g).70, 85 One study developed a protocol based on local committee literature search and 

consensus-building session after investigators realized that their hospital’s infection rate was far 

above the NNIS mean at 7.58 percent.70 The protocol consisted of encouraging all of the 

following: (1) perioperative glucose control; (2) maintenance of strict sterility of the graft and 

sternal wound sites; (3) use of intranasal mupirocin during the perioperative period; (4) postoperative use of a sports bra for women with a cup size of C or larger to reduce pull on the 

incision site; (5) reduction of traffic in and out of the operative suite; (6) administration of the 

prophylactic antibiotic within one hour of incision; (7) a preoperative shower with chlorhexidine. 
43

Specific educational programs emphasized each one of the above to the nursing staff. The 

authors reported a decrease in the surgical site infection rate to 3.47 percent (from 7.58 percent), 

but did not report results for process measures. The study findings are generalizable to other 

interested hospitals because the hospital used standard CDC diagnostic criteria for surgical site 

infections. However, some of the interventions are atypical, and the effectiveness of any one of 

the measures is indeterminate. The other study85 employed a ‘Plan-Do-Check-Act’ continuous 

quality improvement model, and a dedicated infection control practitioner was responsible for 

ensuring compliance. They emphasized several interventions: (1) perioperative glucose control; 

(2) segregation of instruments for graft and sternal wound sites; (3) reduction of traffic in and out 

of the operative suite; (4) administration of the perioperative antibiotic in the holding area; (5) a 

preoperative shower with chlorhexidine. The authors did not report results for these process 

measures. They did note pre-intervention infection rates, and also reported that the mediastinitis 

rate declined from 2.1 percent to 1.5 percent (non-significant trend) and the leg wound infection 

rate declined from 1.93 percent to 0.47 percent (a significant improvement). However, 

mediastinitis rates had risen from 0.8 percent four years prior to the study to 2.1 percent during 

the pre-implementation period without explanation; the subsequent decrease could represent 

regression to mean. The external validity of the study was diminished to some extent because 

the authors did not report the diagnostic criteria for surgical site infections. 

The last study in this group examined whether a handwashing promotion program decreased 

nosocomial infection rates in a neonatal intensive care unit (Table 4g).87 After a prospective 

observational period established baseline infection rates, a special educational program which 

explained the merits of hand washing began for all clinical staff in the neonatal intensive care 

unit, and compliance was subsequently monitored by observers. Hand hygiene compliance 

improved from 43 percent to 80 percent during the promotional period, but surgical site infection 

rates did not show a statistically significant change. External validity was improved because the 

study used CDC criteria for the diagnosis of infection. However, the stated surgical site 

infection rate of 0.33/1,000 patient-days is difficult to interpret, as the number of surgical cases 

was not reported. 

Table 4g. Articles addressing prevention of surgical site infections (studies not using appropriate antibiotic 

prophylaxis as an outcome): simple before-after studies of moderate methodologic quality 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results 

Borer 

200474 Israel 

Tertiary 

care or 

university 

hospital 

1997 

 - 

9/2001 

24 

months 

Hand hygiene 

Appropriate 

use of 

perioperative 

antibiotics 

Decreasing use 

of preoperative 

shaving of the 

operative site 

Improving 

perioperative 

glucose control 

QI Strategies: Clinician education 

A check list of infection control items 

was devised. These consisted of hand 

hygiene, appropriate use of 

perioperative antibiotics, glycemic 

control, and decreasing use of shaving 

of the operative site. In addition to 

these interventions, there was strict 

aseptic techniques used to scrub the 

surgical site; staff couldn't wear fake 

nails or jewelry; staff received 

education and active surveillance was 

performed. 

Infection rate prior 

to intervention: 

4.2% of cases 

Infection rate after 

intervention : 0% 

of cases 

p<0.01 
44

Table 4g. Articles addressing prevention of surgical site infections (studies not using appropriate antibiotic prophylaxis 

as an outcome): simple before-after studies of moderate methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length of 

follow-up 

Preventive 

Interventions 

Quality improvement 

intervention

Results 

Lutarewych 

200470 United 

States 

Not 

specified 

1/2002 

– 

2/2002 

1 year Improving 

perioperative 

glucose 

control 

QI Strategies: Clinician education, 

audit and feedback, patient 

education 

Multiple interventions were 

implemented: 

1) perioperative glucose control 

2) maintenance of strict sterility of 

the graft and sternal wound sites. 

3) use of intranasal mupirocin 

during the perioperative period 

4) use of a sports bra for women 

with a cup size of C or larger to 

reduce pulling on the incision site 

5) reduction of traffic in and out of 

the operative suite 

6) administration of the 

preoperative antibiotic l<1 hour 

before incision 

7) a consistent preoperative 

shower with chlorhexidine 

Improvement in compliance was 

directed to staff to reinforce 

education about other measures. 

Infection rate prior 

to intervention: 

7.58% of cases 

Infection rate after 

intervention: 

3.47% of cases 

p value not 

reported 

Rao 200485 United 

States 

Tertiary 

care or 

university 

hospital 

1/1999 

– 

4/1999 

20 months Appropriate 

use of 

perioperative 

antibiotics 

Decreasing 

use of 

preoperative 

shaving of the 

operative site 

Improving 

perioperative 

glucose 

control 

QI Strategies: Clinician education, 

clinician reminder 

ICP was assigned to the openheart surgery program. ICP 

followed patient from admission to 

discharge and implemented the 

following program: prospective 

surveillance of superficial and 

deep chest and leg infections; 

post discharge follow up of 

patients readmitted within 30 

days; chlorhexidine showers by 

pts the night before/morning of 

surgery; hair removal by clippers 

only; administration of antibiotics 2 

hours before surgical incision; 

segregation of surgical 

instruments; improved glycemic 

control. 

Infection rate prior 

to intervention: 

2.1% Infection 

rate after 

intervention: 1.5% 

p=NS 

Adherence to 

protocols for 

perioperative 

antibiotic 

prophylaxis: 

before 

intervention: 70% 

after intervention: 

92% 

p value not 

reported 

 
45

Table 4g. Articles addressing prevention of surgical site infections (studies not using appropriate antibiotic prophylaxis 

as an outcome): simple before-after studies of moderate methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length of 

follow-up 

Preventive 

Interventions 

Quality improvement 

intervention

Results 

Won 200487 Taiwan 

Tertiary 

care or 

university 

hospital 

9/1998 - 

8/2000 

22 months Hand hygiene QI Strategies: Clinician education, 

audit and feedback 

A multifaceted campaign to 

encourage hand hygiene was 

implemented. All health care 

workers received lectures on 

appropriate use of hand cleansing 

agents, correct hand washing 

techniques, and importance of 

hand washing. This information 

was incorporated into regular 

resident orientation sessions. 

Cartoon reminders were posted 

above each sinks along with 

printed reminders in easily visible 

sites. Observations of hand 

washing were made by other 

NICU nurses, and results posted 

in the NICU each month. One-onone feedback was privately given 

to individual healthcare workers 

who did not perform hygiene 

appropriately, and positive 

reinforcement was given at NICU 

staff meetings. Financial 

incentives were given to nurses as 

an extra monthly bonus, 

individualized by the number of 

correct observed hand washing 

opportunities. The formal lectures 

were discontinued after 2 years, 

but the other measures continued 

for an additional 16 months. 

Infection rate prior 

to intervention: 

0.33% per 1,000 

patient days 

Infection rate after 

intervention: 0.84 

per 1,000 patient 

days 

p=NS 

Adherence to 

protocols for hand 

hygiene: 

before 

intervention: 43% 

after intervention: 

81% 

p<0.01 

Before-After Studies With Poor Internal and External Validity. Several studies met our 

inclusion criteria but had methodological flaws that seriously limited their internal validity or 

applicability (Table 4h).68, 69, 71, 72, 81, 82 One study attempted to reduce the nosocomial infection 

rates using educational programs directed at handwashing but did not use CDC or NNIS criteria 

for measuring surgical site infections and did not conduct post-discharge surveillance.81 Another 

study measured the effect of a comprehensive program of infection control practices but only 

reported one time point before and after the intervention and also did not report the effect on 

process measures.68 In addition, the study’s results translate poorly to current practices because 

the surgical site infection rate was 24.4 percent prior to the intervention and standard CDC 

definitions for wound infections were not used. Two studies involving surgical site infections in 

cardiothoracic surgery patients reported data only immediately before and after the intervention, 

and did not include outcomes for the various prevention interventions.72, 82 One of these studies 

did not report using standard NNIS or CDC criteria to diagnose wound infections;72 the other 

study did not comment on the higher infection rates seen in the middle years of study.82 Another 

study in this category investigated quality improvement in cardiac surgery patients but did not 
46

clearly define pre-intervention period, and defined outcomes in terms of observed/expected 

infection rates but did not state how these were created.69 In addition, pre-intervention 

compliance was not discussed for most interventions in the study. 

A United Kingdom (UK) study examined if using audit and feedback methods could reduce 

surgical site infection rate in the UK.71 The authors extended post-discharge surveillance to 30 

days, and then reported the results to participating surgeons. The overall surgical site infection 

rate significantly declined over 29 months from 13.9 percent to 7.9 percent. However, the 

authors did not report how the surgeons used the information or if concomitant QI efforts were 

underway. In addition, there was significant variation in the monthly infection rate, which was 

not reflected in the before-after statistical analysis. External validity is also limited by the 

relatively high pre-intervention surgical site infection rate. 

Finally, a study conducted in an intensive care unit in a tertiary care center in Guatemala 

examined the effect of an educational program on hand hygiene, aseptic technique and multiple 

nosocomial infections.60 The study included surgical site infection as an outcome, but focused 

on ventilator-acquired pneumonia primarily, and will be discussed in more detail in the VAP 

section. 

Table 4h. Articles addressing prevention of surgical site infections (studies not using appropriate antibiotic 

prophylaxis as an outcome): simple before-after studies of poor methodologic quality 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length of 

follow-up 

Preventive 

Interventions 

Quality improvement intervention Results 

Atukorala 

199881

Sri Lanka 

Tertiary 

care or 

university 

hospital 

1 

month 

Not 

specified 

Hand hygiene QI Strategies: Clinician education, 

organizational change 

The strategy consisted of a broad-based 

increase in infection control measures. 

The number of infection control nurses 

was increased and all health care workers 

underwent educational programs on 

infection control, which stressed hand 

washing as a priority. A liaison nurse was 

identified on each ward to assist the 

infection control nurse. A policy of 

replacing IV catheters every 3 to 4 days 

was instituted and guidelines for urinary 

catheter changes were instituted. Proper 

disposal of clinical waste was initiated. 

Infection rate 

before 

intervention: 

4.44% of 

patients 

Infection rate 

after 

intervention: 

2.72% of 

patients 

p<0.01 

Cavalcante 

199168 Brazil 

Communit

y hospital 

with 

residents 

1986-

1989 

4 years Appropriate 

use of 

perioperative 

antibiotics 

QI Strategies: Clinician education 

"The most important measures 

recommended by the infection control 

committee to decrease the infection rates 

were antibiotic policies, isolation 

precautions, education programs, a 

change to reusable instead of disposable 

material, no routine change of ventilators, 

no local and systemic antibiotic 

prophylaxis, and device procedure policy". 

Education involved 19 basic courses in 

infection control and informal in-services. 

Infection rate 

prior to 

intervention: 

24.4% of 

patients 

Infection rate 

after 

intervention: 

3.4% of 

patients 

p value not 

reported 
47

Table 4h. Articles addressing prevention of surgical site infections (studies not using appropriate antibiotic prophylaxis 

as an outcome): simple before-after studies of poor methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results 

McConkey 

199982 United 

States 

Tertiary 

care or 

university 

hospital 

4/1991- 

12/1994 

3 years Appropriate 

use of 

perioperative 

antibiotics 

Decreasing use 

of preoperative 

shaving of the 

operative site 

Audit and 

feedback of 

infection rates 

to hospitals or 

individual 

clinicians 

QI Strategies: Audit and feedback, 

clinician reminder 

Prospective effort to reduce SSI using 

comprehensive infection control 

program. 

The following interventions were 

instituted: 

1) prospective surveillance; 2) quarterly 

reporting of surgeon and assistant 

specific SSI rates; 3) chlorhexidine 

shower by pt preoperative; 4) Hair 

removal by clipping on morning of 

surgery; 5) antibiotic prophylaxis 1/2 to 

2 hours prior to incision; 6) elimination 

of open ice baths for cooling of 

cardioplegia solution; 7) limitation of OR 

traffic; 8) minimization of intraoperative 

flash sterilization; 9) elimination of tapwater wound bathing within 96 hours 

post-op; 10) sterile wound dressing for 

first 96 hours post-op; 11) use of 

dedicated infection control practitioner. 

Infection rate 

prior to 

intervention: 

12.4% of cases 

Infection rate 

after 

intervention: 

8.2% of cases 

 p<0.01 

Schelenz 

200572 UK 

Hospital 

type not 

specified 

9/2000 

– 

12/2001 

16 

months 

Hand hygiene 

Appropriate 

use of 

perioperative 

antibiotics 

Decreasing use 

of preoperative 

shaving of the 

operative site 

Audit and 

feedback of 

infection rates 

to hospitals or 

individual 

clinicians 

QI Strategies: Clinician education, audit 

and feedback, clinician reminder 

Investigators implemented a bundle of 

different interventions aimed at 

decreasing MRSA wound infections, 

using education, audit and feedback, 

improvements in surgical skin 

preparation, improved antibiotic 

prophylaxis and several measures to 

limit the spread of MRSA. 

Infection rate 

prior to 

intervention: 

4.1% of cases 

Infection rate 

after 

intervention: 

2.1% of cases 

p=NS 

 
48

Table 4h. Articles addressing prevention of surgical site infections (studies not using appropriate antibiotic prophylaxis 

as an outcome): simple before-after studies of poor methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results 

Haycock 

200569 United 

States 

Hospital 

type not 

specified 

4 

months 

1 year Hand hygiene 

Appropriate 

use of 

perioperative 

antibiotics 

Decreasing use 

of preoperative 

shaving of the 

operative site 

Perioperative 

normothermia 

Audit and 

feedback of 

infection rates 

to hospitals or 

individual 

clinicians 

QI Strategies: Clinician education, audit 

and feedback, clinician reminder 

Identified best practices for preventive 

practices and gaps in current practice. 

Formed process teams and 

implemented pilot protocol. Then 

implemented change and modified 

strategy based on results. Intervention 

targeted antibiotic prophylaxis, skin 

preparation, hand hygiene, blood 

glucose control, and wound case 

management for cardiac surgery 

patients. 

Infection rate 

prior to 

intervention: 

1.5% of cases 

Infection rate 

after 

intervention: 

0.3% 

p<0.05 

Adherence to 

protocols for 

hand hygiene: 

Percentage 

change in 

compliance 

rate (post % - 

pre %): 11% 

Adherence to 

administering 

perioperative 

antibiotics for 

the appropriate 

timing: 

before 

intervention: 

NR 

after 

intervention: 

87% 

Adherence to 

appropriate 

selection of 

perioperative 

antibiotics: 

before 

intervention: 

NR 

after 

intervention: 

98% 

Adherence to 

protocols for 

perioperative 

shaving of the 

surgical site: 

before 

intervention: 

NR 

after 

intervention: 

100% 
49

Table 4h. Articles addressing prevention of surgical site infections (studies not using appropriate antibiotic prophylaxis 

as an outcome): simple before-after studies of poor methodologic quality (continued)

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results 

Reilly 

200171 UK 

Not 

specified 

Not 

specified 

28 

months 

Audit and 

feedback of 

infection rates 

to hospitals or 

individual 

clinicians 

QI Strategies: Audit and feedback, 

clinician reminder 

Surveillance including individual risk 

assessment for wound infection, daily 

visits perioperatively, final assessment 

4 weeks post-op. Results collected and 

reported to participating physicians. 

Infection rate 

prior to 

intervention: 

13.9% of cases 

Infection rate 

after 

intervention: 

7.9% of cases 

p<0.05 

*Berg 

199560 Guatemal

a 

Tertiary 

care or 

university 

hospital 

Not 

specified 

1 year Hand hygiene QI Strategies: Clinician education 

A multifaceted intervention was used to 

target nosocomial infections in the ICU, 

with both general measures and 

measures targeting VAP and CAUTI. 

Nurses and physicians received 15 

educational sessions on aseptic 

technique, stressing proper hand 

washing. The educational sessions 

used lectures and demonstrations, and 

individual clinicians also received 

positive and negative feedback and 

reminder signs at the bedside. The 

VAP intervention targeted proper use of 

sterile rinse water and improvement in 

aseptic technique for suctioning. 

Providers received more than 15 

interactive conferences on the 

detection, management, and prevention 

of nosocomial pneumonia; these 

included lectures, demonstrations, 

individual instruction and feedback, and 

contests. The CAUTI intervention 

consisted of changing open urinary 

drainage systems to closed systems 

(aseptic catheter care), with an 

educational session on the new 

catheter. The intervention did not 

specifically target CLABSI, but those 

outcomes are reported. 

Infection rate 

before 

intervention: 

4% of patients 

Infection rate 

after 

intervention: 

5% of patients 

p=Nonsignificant (NS) 

(Note: 

denominator for 

above is all 

patients in ICU; 

number of 

surgical cases 

was not 

provided.) 

*This study addresses prevention of surgical site infections, central line-associated bloodstream infections, ventilator-associated 

pneumonia and catheter-associated urinary tract infections. 
50

Table 5. Quality criteria for simple before-after studies addressing surgical site infections 

Internal Validity External Validity 

Author Did the study 

report data on 

more than one 

time point before 

and after the 

intervention? 

If the study 

reported infection 

rates, did it also 

report process 

measurements? 

Was the 

intervention 

performed 

independent of 

other QI efforts or 

other changes? 

Did the study 

use NNIS/CDC 

methods for 

measuring 

infections? 

Did the study 

perform 

surveillance for 

infections after 

hospital 

discharge? 

Atukorala 

199881 ○ ○ ▲ ▲ ▲

Berg 199560 ● ● ▲ ● ▲

Borer 200474 ● ○ ▲ ● ●

Brusaferro 

199175 ○ ● ▲ ● ●

Cavalcante 

199168 ○ ○ ○ ○ ▲

Dellinger 

200519 ○ ● ▲ ▲ ●

Greco 199161 ● ○ ○ ▲ ▲

Gyssens 

199684 ○ Not applicable ▲ Not applicable Not applicable 

Gyssens 

199680 ○ ● ▲ Not applicable Not applicable 

Haycock 

200569 ● ● ▲ ○ ▲

Larsen 198976 ○ ● ○ ▲ ●

Lutarewych 

200470 ○ ○ ○ ● ●

McConkey 

199982 ○ ○ ▲ ● ●

Prado 200283 ○ ● ○ ○ ▲

Rao 200485 ● ● ▲ ○ ●

Reilly 200171 ○ ○ ▲ ○ ●

Schelenz 

200572 ○ ○ ○ ○ ▲

Shapiro 198165 ○ Not applicable ○ Not applicable Not applicable 

Smith 198877 ○ Not applicable ○ Not applicable Not applicable 

St Jacques 

200578 ○ Not applicable ▲ Not applicable Not applicable 

Talon 200173 ○ Not applicable ▲ Not applicable Not applicable 

Won 200487 ○ ● ▲ ● Not specified 

● Yes ○ No ▲Unclear
51

Central Line-Associated Bloodstream Infections 

Included Studies: Settings, Goals, and Target Populations 

Our literature search identified 19 studies that met our inclusion criteria that specifically 

addressed prevention of central line-associated blood stream infection (CLABSI) (Tables 6a-6e). 

One of the studies60 reported data on CLABSI rates, but primarily addressed VAP prevention. 

This study will be discussed in detail in the section on VAP but will not be included in the 

analysis of CLABSI. This left 18 studies for analysis. Ten of the 18 studies were from centers 

within the United States88-97 and eight were from outside the United States.62, 98-104 Seventeen of 

the studies specifically targeted reduction of CLABSI, while one62 targeted CLABSI and VAP. 

All but one of the studies was from a single center. One study96 reported data from multiple 

hospitals that varied from tertiary teaching centers to community non-teaching hospitals. Of the 

remaining studies, 14 were from tertiary care medical centers and three from community 

hospitals. One of these community hospitals had residents,100 while the other two were nonteaching centers.92, 102 One study104 did not report the type of hospital. Most studies took place 

in ICUs. One study was from a bone marrow transplant unit90 and two did not state the type of 

unit that was studied.91, 104 One study was located in a neonatal ICU62 and the remaining studies 

were from adult medical or surgical ICUs. 

All of the studies reported rates of CLABSI; nine of the studies also reported data on process 

measurements.89-93, 96, 100, 101, 103 The study populations were highly variable, with baseline 

CLABSI ranging from 2.7 episodes of CLABSI/1,000 catheter-days96 to 45.9 CLABSI/1,000 

catheter-days.102 The range of study duration was 4-39 months, with the median being 23 

months. Four studies62, 96, 98, 104 did not report duration. 

Preventive Interventions and Outcomes Measured 

We identified hand hygiene, use of maximal sterile barrier precautions, appropriate insertion 

site selection, chlorhexidine skin disinfection, and prompt removal of unnecessary catheters as 

target preventive interventions for this review (Tables 6a-6e). All studies but two92, 97 targeted 

hand hygiene; the next most common targeted strategy was maximal sterile barrier precautions. 

Five studies targeted hand hygiene alone,62, 88, 98, 100, 104 four targeted hand hygiene and maximal 

sterile barrier precautions,90, 91, 101, 103 and seven studies targeted hand hygiene, maximal sterile 

barrier precautions, and at least one other preventive strategy89, 93-96, 99, 102 (Tables 6a-6e). A 

number of included studies also attempted to reduce CLABSI by improving nursing care of 

catheters already in situ.88, 89, 99 We did not consider in situ catheter care as a target preventive 

intervention as there is a stronger evidence base supporting proper insertion practices as effective 

means of preventing CLABSI, but these interventions may have contributed to the observed 

effects in these studies. 

Quality Improvement Strategies Used 

Tables 6a-6e list the QI strategies employed in each study and provide details on the QI 

intervention. All but one of the studies employed educational strategies for health care providers 

as part of their intervention (Lam62 did not include provider education). Most of the educational 
52

programs were for nurses and physicians;88, 89, 91-94, 96, 97, 99-104 one study only provided education 

for nurses90 and another only for physicians.95 One study98 did not specify who was given 

education. Most educational interventions involved distributed educational material88, 89, 92, 94-96, 

99, 102-104 or lecture format.89, 91-94, 96, 97, 100-102, 104 Three particularly intensive educational 

programs combined distributed material, lectures, and interactive workshops.92, 93, 102 Other 

modes of provider education used in the studies were consensus-building sessions,88 distribution 

of “promotional materials”,89 and academic detailing.90, 101 The majority of studies that used 

education used more than one modality for delivery of educational content. 

In addition to provider education, the strategies of audit and feedback, clinical reminders, and 

organizational change were employed to encourage behavioral change. Eleven studies employed 

audit and feedback,88, 90, 92-97, 100-102 five employed strategies that included organizational 

change,62, 90, 96-98, 100 and four used clinical reminders.62, 90, 96, 101 Seven studies used two different 

strategies,62, 88, 92, 93, 95, 98, 102 five used only provider education,89, 91, 99, 103, 104 three studies 

employed three of the strategies,97, 100, 101 and two studies used all four strategies to encourage 

behavioral change.90, 96 

Study Methodologic Quality 

The methodological quality of studies was limited, as all but two used a quasi-experimental, 

before-after design (Tables 6a-6e). In addition, there was extensive variability in the duration of 

studies and whether the intervention ran in series or coincident with the period measuring the 

intervention’s effect. To help facilitate comparison between studies and qualitative analysis, we 

developed criteria to characterize internal and external validity for simple before-after studies 

(Table 7). One study met all three criteria for internal validity.100 Eight studies met two out of 

three,88, 89, 91-93, 96, 101, 103 three studies met one out of three,90, 95, 97 and five studies met none.62, 98, 

99, 102, 104 Most studies met criteria for external validity. Only three studies did not measure 

CLABSI by NNIS/CDC definitions,90, 95, 98 and three studies did not report infection rates in 

terms of days of device utilization.90, 102, 104

Given the heterogeneous study groups, the variety of specific interventions, and the 

significant methodological limitations of all the included studies, we were not able to perform 

quantitative analysis of the data. We will summarize the studies that we considered to have 

generally stronger internal and external validity. 

Controlled Before-After Studies. One study94 measured the effect of their intervention in an 

ICU that cares for patients undergoing general, orthopedic, transplant, trauma, and vascular 

surgery, and compared the results to a concurrent control ICU that cares for patients undergoing 

cardiac surgery (Table 6a). An interdisciplinary team of physicians, nurses, and infection control 

practitioners implemented five interventions over a period of nearly two years: (1) education of 

staff to increase provider awareness of evidence-based infection control practices (a hospitalwide intervention which also targeted providers in the control ICU). All physicians or physician 

extenders who inserted CVCs were required to complete a Web-based training module and 10-

question posttest. Completion of the module was required for physicians. Infection control staff 

also provided 16 lectures for nurses and five for physicians to reinforce the guidelines. Monthly 

CLABSI rates were posted in the SICU; (2) a central catheter insertion cart containing all the 

materials needed to properly insert a CVC was introduced on the study unit; (3) the ICU team 

began asking whether catheters could be removed every day during rounds, and added this 
53

Table 6a. Articles addressing prevention of central line-associated bloodstream infections (CLABSI): 

controlled studies 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

Berenholtz 

200494 United 

States 

Tertiary 

care or 

university 

hospital 

2/1999-

12/2001 

2 years Hand hygiene 

Maximal sterile 

barrier 

precautions 

Appropriate 

insertion site 

selection 

Chlorhexidine 

skin 

disinfection 

Prompt 

removal of 

unnecessary 

catheters 

QI Strategies: Clinician education, audit 

and feedback 

Multiple interventions to reduce CLABSI 

were introduced in a staggered fashion. 1) 

Beginning 2/1999, all physicians or 

physician extenders who inserted CVCs 

were required to complete a Web-based 

training module and 10-question posttest. 

The training module emphasized hand 

hygiene, maximal sterile barrier 

precautions, chlorhexidine skin 

sterilization, and subclavian site as the 

preferred insertion site. It also addressed 

the care of central lines after insertion. In 

2002, completion of the module was 

required for physicians. Infection control 

staff also provided 16 lectures for nurses 

and five for physicians to reinforce the 

guidelines. Monthly CLABSI rates were 

posted in the SICU. 2) A central catheter 

insertion cart containing all the materials 

needed to insert a CVC was introduced in 

6/1999. 3) Beginning 6/2001, the ICU 

team began asking whether catheters 

could be removed every day during 

rounds, and added it to the daily goals 

form for each patient. 4) A standardized 

checklist for CVC insertion, completed by 

nurses, was introduced in 11/2001. 5) 

Beginning 12/2001, nurses were 

empowered to stop insertion of a CVC if 

the checklist was not followed (except in 

an emergency.) 

Intervention 

group: 

Before 

intervention: 

11.3 CLABSI 

per 1,000 

catheter-days 

After 

intervention: 

0 CLABSI per 

1,000 

catheter-days 

Control 

group: 

Before 

intervention: 

5.7 CLABSI 

per 1,000 

catheter-days 

After 

intervention: 

1.6 CLABSI 

per 1,000 

catheter-days 

p value for 

comparison 

of change in 

intervention 

group versus 

change in 

control group 

= NS 
54

Table 6a. Articles addressing prevention of central line-associated bloodstream infections (CLABSI): controlled studies 

(continued) 

Author Setting and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

Eggimann 

200099 Switzerland 

Tertiary care 

or university 

hospital 

3/1997 

- 

4/1997 

8 

months 

Hand hygiene 

Maximal sterile 

barrier 

precautions 

Chlorhexidine 

skin 

disinfection 

Prompt 

removal of 

unnecessary 

catheters 

QI Strategies: Clinician education 

A multiple-approach intervention strategy 

targeted at the reduction of vascularaccess infections was implemented in 

March 1997. An educational campaign 

consisting of 30-min slide-shows and 

practical demonstrations was developed 

for all medical ICU staff (21 fellows or 

residents, 82 nurses, and 15 nursing 

assistants), and was completed by 

individual in-service training. The 

guidelines covered the following: 

preparation of the material to avoid any 

interruption during insertion; skin 

preparation (hair-cutting instead of 

shaving) and disinfection (alcohol-based 

solution of chlorhexidine gluconate 0·5%, 

with 2 min drying time); maximum barrier 

precautions (sterile gloves and gown, cap, 

mask, and a large sheet) used for all but 

peripheral lines; subclavian or wrist vein 

as standard insertion sites; and dressings 

(dry gauze covered by a non-occlusive 

adhesive band). Administration sets, 

devices, and dressings were replaced 

every 72 h, except for lines receiving lipid 

or blood products, and for the first 

dressing after catheter insertion 24 h. 

Hand disinfection was strongly 

emphasized before and after the insertion, 

replacement, or manipulation of any 

vascular device. Central lines were not 

routinely replaced, but were changed over 

a guidewire in cases of clinical sepsis 

without documented source of infection. 

Prompt removal of any device not 

intended for use was strongly 

recommended. 

Infection rate 

prior to 

intervention: 

3.1 

microbiologic

ally 

documented 

CLABSI per 

1,000 

catheter-days 

Infection rate 

after 

intervention: 

1.2 CLABSI 

per 1,000 

catheter-days 

p<0=0.04 

prompt to the daily goals form for each patient; (4) a standardized checklist for CVC insertion, 

completed by nurses, was implemented; (5) nurses were empowered to stop procedures if 

guidelines contained in the checklist were not followed. The cumulative intervention targeted 

hand hygiene, maximal sterile barrier precautions, chlorhexidine skin disinfection, and 

subclavian vein as the preferred insertion site. It also addressed the care of central lines after 

insertion. Cases were defined by NNIS criteria, and the data were normalized to days of device 

usage. CLABSI rates in the study unit decreased from 11.3/1,000 catheter-days in the quarter 

before the beginning of the intervention to 0/1,000 catheter-days in the quarter when nurses were 

empowered to stop the procedure if guidelines were not followed. The control unit also saw a 

decrease in rates of CLABSI, from 5.7/1,000 catheter-days to 1.6/1,000 catheter-days over the 

same time period. Study data were analyzed by using a Poisson regression model to model the 
55

change in infection rates over time and by comparing the slopes and intercepts of the regression 

lines for the intervention and control groups. There was no significant difference between the 

regression lines for either slope or intercept. This raises the possibility that the educational 

intervention (which was delivered to both groups) may have entirely accounted for the 

intervention effect. No process measures were reported. A subsequent report documented 

sustained reductions in CLABSI over an additional 18 months of followup.105

An educational campaign aimed at reducing CLABSI was the main intervention in another 

controlled study out of the medical ICU of a large tertiary medical center in Geneva, Switzerland 

(Table 6a).99 The program consisted of 30-minute slide shows and practical demonstrations and 

was given to all medical intensive care unit (MICU) staff (fellows, residents, nurses, nursing 

assistants). Among our targeted interventions, proper hand hygiene, use of chlorhexidine for 

skin preparation, maximal sterile barrier precautions, and use of the subclavian vein as the 

preferred site were specifically addressed. Rates of CLABSI before and after the educational 

campaign were compared to rates in the surgical ICU (SICU) of the same hospital; the authors do 

not comment how isolated the units are, and it is possible that there was crossover among unit 

personnel. The study did not report data at multiple time points and did not report process 

measures. Data for arterial and central venous lines were reported in aggregate. Rates of 

CLABSI decreased from 11.3/1,000 catheter-days to 3.8/1,000 catheter-days in the MICU (study 

unit), while they were unchanged during the same period in the control SICU (10.3/1,000 

catheter-days before and 11.6/1,000 catheter-days after the educational campaign). A subsequent 

report documented a sustained reduction in CLABSI over six years of follow-up.106

Interrupted Time Series Studies. A yet to be published study employed a complex multiple 

time series design.96 This project took place in 107 separate ICUs in the state of Michigan over a 

one-year period. Study ICUs were diverse, ranging from small non-teaching community 

hospitals to large tertiary academic centers; both surgical and medical ICUs were included. In 

addition to an intervention to reduce CLABSI, participating ICUs sequentially introduced a 

“Daily Goals Sheet” to improve communication among healthcare personnel, a multi-faceted 

intervention to reduce ventilator-associated pneumonia, and a comprehensive unit-based safety 

program to improve safety culture. 

The implementation period for each of the four interventions was estimated to take three 

months. Hospitals were asked to start with the comprehensive unit-based safety program, and 

then choose the implementation order for the remaining three patient safety interventions during 

the 12-month period. The included manuscript comments only on the intervention to reduce 

CLABSI; it does not give details of the nature or outcomes of the other patient safety programs. 

Before implementing any patient safety intervention, each ICU designated at least one 

physician and nurse as team leaders. For CLABSI, interventions were washing hands prior to 

the procedure, using full barrier precautions, cleaning the skin around the insertion site with 

chlorhexadine, avoiding the femoral site if possible, and removing unnecessary catheters. A 

bundle of six strategies was used to increase adherence to these targeted interventions, similar to 

those used in a prior study:94 (1) ICU clinicians were educated to increase their awareness of 

evidence-based infection control practices and to review the harm caused by CLABSI; (2) A 

central catheter insertion cart containing all the materials needed to properly insert a CVC was 

introduced on the study unit; (3) the ICU team began asking whether catheters could be removed 

every day during rounds, and added it to the daily goals form for each patient; (4) A standardized 

checklist for CVC insertion, completed by nurses, was implemented; (5) Nurses were 
56

empowered to stop procedures if guidelines contained in the checklist were not followed; and (6) 

teams were provided with monthly feedback regarding the number of CLABSI and quarterly 

feedback regarding rates of CLABSI in their ICU. 

Data was acquired at baseline and at three-month intervals. The sequential nature of the 

implementation and time frame of the study meant that no single center had a complete data set; 

data from all of the study centers was analyzed in aggregate. As a result, the population of 

centers included in the baseline data set and subsequent post-intervention data sets had 

significant overlap, but were not identical. Cases of CLABSI were defined by NNIS criteria and 

reported normalized to days of device utilization. Data reported as median CLABSI/1,000 

catheter-days for each time period among the ICUs included at each time point. The median preintervention rate of CLABSI was 2.8/1,000 catheter-days. This decreased to 1.7 during the 

three-month peri-intervention period, and then to zero during each of the subsequent periods 

post-intervention. Thus, more than half of the study ICUs reported no cases of CLABSI up to 

nine months following implementation of their quality improvement strategy. The difference 

between the pre- and post- intervention rates of CLABSI was statistically significant (p=0.002); 

multi-level Poisson regression model (time series analysis) demonstrated a significant decrease 

in CLABSI rates during all observation periods (versus pre-intervention baseline). 

Though the reported results are impressive, aspects of the study design and data collection 

limit the interpretability of its results. Most significantly, the current study focuses on an 

intervention to prevent CLABSI, but in reality the intervention involved a variety of 

interventions targeting patient safety and HAIs, which could have contributed to the observed 

effect in addition to the CLABSI-specific intervention. There were also problems with internal 

validity. Of the 1,176 ICU-months of data, 25 percent were not available. While a sensitivity 

analysis was performed and statistical significance was maintained, this is a large amount of data 

unaccounted for; it might be expected that those centers not reporting data have a higher rate of 

CLABSI. In addition, as described above, the population of ICUs included in the baseline data is 

not the same as that studied after implementation of the intervention, introducing the potential 

for sampling error. 
57

Table 6b. Articles addressing prevention of central line-associated bloodstream infections: interrupted time series 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention 

Pronovost 

(unpublish

ed)96

United 

States 

Multiple 

hospitals 

of 

different 

types 

3/2004 

– 

2/2005 

3 

months 

Hand hygiene 

Maximal sterile 

barrier 

precautions Appropriate 

insertion site 

selection 

Chlorhexidine 

skin 

disinfection 

Prompt 

removal of 

unnecessary 

catheters 

QI Strategies: Clinician education, audit and feedback, clinician reminder, organizational change Using a multiple time series design, Keystone ICU involved individual ICUs implementing several different patient safety interventions and monitoring ththese interventions on specific safety measures. In addition to the multi-faceintervention to reduce CLABSI, ICUs implemented a “Daily Goals Sheet” to communication between clinicians in the ICU, a multi-faceted intervention to ventilator-associated pneumonia, and a comprehensive unit-based safety pr(CUSP) to improve safety culture. The implementation period for each intervention was estimated to take three Hospitals were asked to start with CUSP and then choose the implementatiothe remaining three patient safety interventions during the 12-month period. Before implementing any patient safety intervention, each ICU designated aphysician and nurse as team leaders. These team leaders were given detaiand then were responsible for disseminating the interventions to their collealeaders participated in biweekly conference calls and attended two state-widduring the year. For each intervention, teams were provided a manual of op

that included details regarding the efficacy of the intervention, evidence sup

intervention, suggestions for implementing the intervention, and methods of collection. Interventions were: washing hands prior to the procedure, using full barrier cleaning the skin around the insertion site with chlorhexadine, avoiding the fif possible, and removing unnecessary catheters. The strategy to increase the use of these evidence-based interventions had components, as described in detail elsewhere. First, ICU clinicians were edincrease their awareness of evidence-based infection control practices and the harm caused by CLABSI. Second, a cart with all supplies and equipmenfor central line insertion was created to reduce the number of steps necessapreparing for safe and sterile line insertion. Third, a central line insertion ch

used by the ICU bedside nurse to help ensure a safe and sterile procedure. nurses were empowered to stop a central line insertion (in non-emergency sproviders did not comply with evidence-based infection control practices. Fifdiscussed whether central lines could be removed during daily physician rouFinally, monthly feedback was provided to teams regarding the number of C

quarterly feedback regarding rates of CLABSI in their ICU. 
58

Before-After Studies With Good Internal and External Validity. Only one study met all of 

our criteria for internal and external validity (Table 6c).100 This study, out of Mexico City, used 

a combination of education, audit and feedback, and organizational change to encourage 

behavioral change in a medical-surgical ICU and a neurologic-ICU. The education component 

consisted of one-hour classes given by an infection control nurse to unit nurses and residents. 

The investigators performed active surveillance of hand hygiene and catheter care practices; 

performance feedback consisted of charts posted in the units with unit level data on hand hygiene 

and invasive device care. Cases of CLABSI were defined by NNIS criteria. The intervention led 

to a reduction of CLABSI from 46.3 events/1,000 catheter days to 19.5. The authors also 

demonstrated an improvement in process measures, with optimal hand hygiene improving from 

62 percent to 85 percent of observed cases. A major limitation to the study was the high baseline 

rate of CLABSI, which likely was related to resource availability at the study center. Part of the 

hand hygiene component of the study involved a hospital-wide switch from non-antiseptic soap 

to alcohol hand rub or povidone-iodine soap. 

A pair of studies carried out in a surgical ICU in a single teaching hospital reported 

consecutive interventions to reduce CLABSI (Table 6c). The first study88 was an educational 

program targeted primarily at nurses. The main intervention was a 10-page self-study module 

that every nurse was expected to complete, along with a pre- and post-test. Unit-level monthly 

feedback of rates of CLABSI was posted, along with fact sheets and posters. Of note, housestaff 

did not receive the educational program but were responsible for placing all central lines under 

supervision of faculty and/or fellows. The educational module covered background information 

about CLABSI and methods to decrease risk. Of our targeted interventions, optimal hand 

hygiene and preferred insertion site (subclavian vein optimal, femoral vein only in emergency 

situations) were specifically addressed. Other techniques to reduce the risk of CLABSI focused 

on catheter maintenance. This study was not a time series analysis but did report data at multiple 

time points before and after the intervention. Process measures were not reported. CLABSI 

rates decreased from 10.8 cases/1,000 catheter-days before the intervention to 3.7 cases/1,000 

catheter-days afterward. Subsequent to this study, the same group attempted another 

intervention to improve adherence to optimal risk reduction behaviors.89 Using a series of 

bedside audits to define current practice patterns, a multifactorial behavioral intervention was 

designed. Pictures demonstrating each step of CVC maintenance and insertion were placed at 

every patient’s bed, throughout the ICU, and in the manual each resident receives when they 

rotate through the ICU. Nurses received lectures and hands-on demonstrations were given to 

nurses as part of their annual skills sessions. Lectures were given to the entire resident staff, and 

monthly lectures were given to all residents rotating through the ICU. A second set of bedside 

audits was performed to assess the success of the behavioral intervention, and CLABSI rates 

were monitored concurrently with the study. Data was reported at multiple time points before 

and after the intervention, but a formal time series analysis was not performed. Only ten central 

line insertions were actually audited after the intervention, limiting the findings regarding 

behavioral change improvement. The intervention was associated with improved adherence to 

appropriate hand hygiene (17 percent to 30 percent), maximal sterile barrier precautions (50 

percent to 80 percent) and appropriate catheter site selection (53 percent to 60 percent). No other 

process measures were reported. The rate of CLABSI was 3.4/1,000 catheter-days before the 

intervention and 2.8/1,000 catheter-days afterward. 

Two other studies out of the same integrated healthcare system as the previous two reports 

used a similar educational intervention to reduce CLABSI (Table 6c).92, 93 One of these92 was 
59

distinguished by the fact that it was in non-teaching, community hospital and included a medical 

and surgical ICU. For this intervention, all ICU nurses and physicians had to complete a 10-page 

self-study module on the prevention of CLABSIs; the module was similar to the one described 

above.88 Nursing and medical staff received a 45 minute lecture on CLABSI, and grand rounds 

on prevention of CLABSI were presented to the medical staff. Among our targeted 

interventions, maximal sterile barrier precautions and appropriate catheter site selection were 

covered in the educational program. Posters and fact sheets were placed in the ICU. A pretest 

and posttest was administered to ICU nurses; the pretest was optional but the posttest was 

mandatory. All physicians completed the posttest as well. Rates of CLABSI were 4.9/1,000 

catheter-days before the intervention, and 2.1/1,000 catheter-days afterward. Rates of adherence 

to appropriate catheter site selection improved from 25 percent to 41 percent. All catheters used 

in this study were impregnated with chlorhexidine and silver-sulfadiazine. The same 

investigators also reported the results of an intervention in the MICU of a large tertiary academic 

medical center.93 A multidisciplinary committee made local modifications to the educational 

module already described;88 the program was administered to all nurses and physicians working 

on the unit. In addition, a promotional campaign was carried out that included distribution of 

lapel buttons, fact sheets, posters; photographic guidelines demonstrating proper insertion and 

catheter care techniques were placed in prominent locations in the ICU. Feedback was provided 

in the form of monthly reports of CLABSI rates, which were posted in multiple locations 

throughout the unit. Data were reported from multiple time points before and after the 

intervention, but a formal time-series analysis was not performed. CLABSI rate improved from 

9.4 cases/1,000 catheter-days before the intervention to 5.5 cases/1,000 catheter-days after the 

procedure. The education did not change provider behaviors regarding catheter site selection; 26 

percent of insertion sites were deemed appropriate before the intervention compared to 20 

percent afterward. Notably, there was a QI program targeting Ventilator-Associated Pneumonia 

running concurrently with this study. There could have been significant crossover in effect 

between the interventions, making the results less reliable. 

This study, like the three others from this healthcare system,88, 89, 93 is subject to a certain 

amount of bias due to the fact that there was intense system-wide effort to reduce overall healthcare associated infections, a fact which by itself might influence the findings. 

Another study using an educational intervention targeted medical students and interns (Table 

6c).91 As part of a half-day course on performing a variety of medical procedures, interns and 

students received a one-hour lecture on basic infection control principles, including hand 

washing and appropriate use of barrier garments. Attendees then went through a series of onehour workstations, one of which was dedicated to proper insertion of arterial and central venous 

catheters. This module specifically addressed hand hygiene and maximal sterile barrier 

precautions. Data on the effectiveness of the intervention was collected in six medical-surgical 

ICUs and their associated step-down units and was reported at multiple time points. Cases were 

defined by CDC criteria. Use of full-sized drapes was assessed by measuring the surrogate 

marker of purchasing records and improved from 44 percent to 65 percent after the intervention. 

Rate of CLABSI decreased from 4.51 to 2.92 cases/1,000 patient-days. Rates of infection 

normalized to catheter days were estimated, but not actually measured. 
60

Table 6c. Articles addressing prevention of central line-associated bloodstream infections: simple beforeafter studies of good methodologic quality 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

Higuera 

2005100 Mexico 

Community 

hospital 

with 

residents 

phase 1 

6/ 2002 

– 

8/ 2002; 

phase 2 

9/ 2002 

- 

5/2003 

9 

months 

Hand hygiene QI Strategies: Clinician education, audit 

and feedback, organizational change 

The overall strategy was referred to 

process control. Targeted processes 

were hand hygiene and catheter care. 

The study was in Mexico, where routine 

maintenance catheter was very 

substandard compared to US practice. 

The investigators reported using 

education, process control, performance 

feedback, and direct observation. The 

education process was led by an 

infection control nurse who presented 

one hour classes to nurses and 

residents. Performance feedback 

consisted of charts posted in the units 

with unit level data on hand hygiene and 

invasive device care. 

Infection rate prior 

to intervention : 

46.3 CLABSI per 

1,000 catheterdays 

Infection rate after 

intervention: 19.5 

CLABSI per 1,000 

catheter-days 

p<0.01 

Adherence to 

protocols for hand 

hygiene: 

before 

intervention: 62% 

after intervention: 

84.9% 

p<0.01 

Coopers

mith 

200288

United 

States 

Tertiary 

care or 

university 

hospital 

7/1999 -

12/2000 

18 

months 

Hand hygiene QI Strategies: Clinician education, audit 

and feedback 

This was an educational intervention 

targeted primarily at nurses, but also at 

physicians. The main intervention was a 

10-page self study module that every 

nurse was supposed to complete, along 

with a pre- and post-test. Specific risk 

reduction strategies addressed included: 

handwashing & aseptic technique, 

methods for detection potential clinical 

signs & symptoms of local infection, 

technique for sending catheter-tip culture, 

routine catheter site care, replacing 

administration sets & fluids, cleaning & 

changing injection ports & luer lock caps, 

how to handle parenteral fluids & 

multidose vials & procedure for drawing 

blood cultures. The program also 

involved verbal inservice raining at staff 

meetings. Each participant took a pretest 

before the study module and an identical 

test upon completion. Fact sheets & 

posters reinforcing this information were 

posted throughout the ICU. 

Infection rate prior 

to intervention: 

10.8 CLABSI per 

1,000 catheterdays 

Infection rate after 

intervention: 3.7 

CLABSI per 1,000 

catheter-days 

p<0.01 
61

Table 6c. Articles addressing prevention of central line-associated bloodstream infections: simple before-after studies 

of good methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

Coopers

mith 

200489

United 

States 

Tertiary 

care or 

university 

hospital 

11/2000 

- 2/2002 

 Hand hygiene 

Maximal sterile 

barrier 

precautions 

Appropriate 

insertion site 

selection 

QI Strategies: Clinician education 

Used a literature-based determination of 

risk factors involved in catheter 

infections to develop an audit tool to 

determine whether randomly checked 

CVCs were properly maintained or 

whether new insertions were performed 

under sterile conditions. 

After these bedside audits, a behavioral 

intervention was designed. The 

intervention was multifactorial. Pictures 

demonstrating each step of CVC 

maintenance (aimed at nursing staff) 

and insertion (aimed at physicians) 

were placed at every patient’s bed, 

throughout the ICU, and in the manual 

each resident receives when they rotate 

through the ICU. Lectures and hands-on 

demonstrations were given to nurses as 

part of their annual skills sessions by 

two of us (C.S.S. and M.E.S.). Lectures 

were given to the entire resident staff in 

the departments of surgery and 

emergency medicine by one of us 

(C.M.C.), and monthly lectures were 

given to all residents rotating through 

the ICU. To assess the success of the 

behavioral intervention, a second set of 

bedside audits was performed from 

November 2001 through February 2002. 

Infection rate prior 

to intervention: 3.4 

CLABSI per 1,000 

catheter-days 

Infection rate after 

intervention: 2.8 

CLABSI per 1,000 

catheter-days 

p=NS 

Adherence to 

protocols for hand 

hygiene: 

before intervention: 

17% 

after intervention: 

30% 

Adherence to 

appropriate use of 

maximal sterile 

barrier precautions: 

before intervention: 

50% 

after intervention: 

80% 

Adherence to 

appropriate catheter 

site selection: 

before intervention: 

53% 

after intervention: 

60% 

p=NS for all 

process measures 
62

Table 6c. Articles addressing prevention of central line-associated bloodstream infections: simple before-after studies 

of good methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

Warren 

200392 United 

States 

Nonteaching 

communit

y hospital 

7/1999 - 

9/1999 

2 years Maximal sterile 

barrier 

precautions 

Appropriate 

insertion site 

selection 

QI Strategies: Clinician education, audit 

and feedback 

An educational intervention targeting 

CLABSI was administered to the clinical 

staff in a community hospital ICU. 

Nursing and medical staff received a 45 

minute lecture on CLABSI, and grand 

rounds on prevention of CLABSI were 

presented to the medical staff. Posters 

and fact sheets were placed in the ICU 

(the content of these was not specified.) 

CLABSI rates were reported to all ICU 

staff. All ICU nurses and physicians 

had to complete a 10-page self-study 

module on the prevention of CLABSIs, 

based on the 1996 HICPAC guidelines. 

These emphasized maximal sterile 

barrier precautions, preference for 

subclavian vein insertion, and 

guidelines for changing intravenous 

tubing and administration sets as well 

as proper technique for blood cultures. 

A pretest and posttest was administered 

to ICU nurses; the pretest was optional 

but the posttest was mandatory. All 

physicians completed the posttest as 

well. 

Infection rate prior 

to intervention: 4.9 

CLABSI per 1,000 

catheter-days 

Infection rate after 

intervention: 2.1 

CLABSI per 1,000 

catheter-days 

P<0.01 

Adherence to 

appropriate catheter 

site selection: 

before intervention: 

25% 

after intervention: 

41% 

p<0.01 
63

Table 6c. Articles addressing prevention of central line-associated bloodstream infections: simple before-after studies 

of good methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

Warren 

200493 United 

States 

Tertiary 

care or 

university 

hospital 

1/ 2002 

-

12/2003 

2 years Hand hygiene 

Maximal sterile 

barrier 

precautions 

Appropriate 

insertion site 

selection 

QI Strategies: Clinician education, audit 

and feedback 

An educational intervention targeting 

CLABSI was administered to the clinical 

staff in a medical ICU at a teaching 

hospital. The ICU infection control team 

developed policies and procedures for 

catheter insertion and site maintenance 

and developed a strategy for education 

and implementation. The intervention 

consisted of the following: Nursing and 

medical staff received a 45 minute 

lecture on CLABSI. Posters and fact 

sheets were placed in the ICU at 

computer terminals (the content of 

these was not specified.) All ICU nurses 

and physicians had to complete a 10-

page self-study module on the 

prevention of CLABSIs, based on the 

HICPAC guidelines. These emphasized 

the following: hand hygiene, maximal 

sterile barrier precautions, avoidance of 

femoral catheterization, hair removal 

with clippers, avoidance of antimicrobial 

ointment at the insertion site, avoidance 

of changing catheters over guidewires, 

and guidelines for changing intravenous 

tubing and administration sets. A pretest 

and posttest was administered to 

nurses and physicians. CLABSI rates 

were reported to all ICU staff. A 

promotional campaign was also 

launched with distribution of lapel 

buttons, fact sheets, posters, and 

photographic guidelines demonstrating 

proper insertion and catheter care 

techniques in prominent locations in the 

ICU. 

Infection rate prior 

to intervention: 9.4 

CLABSI per 1,000 

catheter-days 

Infection rate after 

intervention: 5.5 

CLABSI per 1,000 

catheter-days 

Adherence to 

appropriate catheter 

site selection: 

before intervention: 

26.3% 

after intervention: 

20.4% 

p=NS 
64

Table 6c. Articles addressing prevention of central line-associated bloodstream infections: simple before-after studies 

of good methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

Sherertz 

200091 United 

States 

Tertiary 

care or 

university 

hospital 

06/1996 

and 

06/1997 

6 

months 

Hand hygiene 

Maximal sterile 

barrier 

precautions 

QI Strategies: Clinician education 

PGY-1 residents and medical students 

underwent a 1/2-day educational 

session on infection control practices for 

procedures. Infection control 

practitioners and an epidemiologist 

gave a 1-hour lecture on basic infection 

control principles, including hand 

washing. The subjects then rotated 

through a series of 1-hour stations at 

which they received didactic and handson instruction on the following 

procedures: insertion of central venous 

and arterial catheters, blood draws 

through vascular lines, arterial puncture, 

urinary catheter insertion, lumbar 

puncture, peripheral venous catheter 

insertion, and phlebotomy. The handson stations used mannequins. 

Infection rate prior 

to intervention: 4.51 

CLABSI per 1,000 

patient-days 

Infection rate after 

intervention: 2.92 

CLABSI per 1,000 

patient-days 

p<0.01 

Adherence to 

appropriate use of 

maximal sterile 

barrier precautions: 

before intervention: 

44% 

after intervention: 

65% 

p<0.01 

Before-After Studies With Moderate Iinternal and External Validity. A study from Korea 

used a combination of education and intensive surveillance and active feedback to reduce the rate 

of CLABSI (Table 6d).103 The infection control committee held “Infection Control Week”, 

during which new guidelines for central line care, aseptic technique, and hand washing were 

distributed. Details of the educational program were not provided. Infection control staff 

conducted daily surveillance of all central lines to monitor for appropriate catheter care, 

including hand washing, occlusive dressing, and aseptic application of povidone iodine, and gave 

direct feedback if protocols were violated. Rates of CLABSI decreased from 4.2/1,000 catheterdays before the intervention to 1.3/1,000 catheter-days afterward, but these results are nonsignificant due to the very small size of the study. The data reflect only six actual cases of 

CLABSI. 

A study conducted in a surgical intensive care unit of a tertiary care hospital used corporate 

“Six Sigma” methodology, which focuses on minimizing variability and improving efficiency, to 

target CLABSI (Table 6d).97 A multidisciplinary team consisting of SICU staff and hospital 

epidemiologists developed an educational module for residents and guidelines for catheter care 

and changing catheters over guidewires. Additionally, attending staff were required to supervise 

non-emergent catheter insertion, and infection rates were fed back to SICU staff. The study had 

good external validity and reported data at more than one time point before and after the 

intervention, but did not measure adherence. CLABSI were significantly reduced, however, the 

results of the QI intervention were likely significantly confounded by the simultaneous 

introduction of antibiotic-coated catheters42 for patients requiring long-term (greater than four 

days) mechanical ventilation; these had not been used in the baseline phase of the study. 
65

Table 6d. Articles addressing prevention of central line-associated bloodstream infections: simple beforeafter studies of moderate methodologic quality

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

Yoo 

2001103 Korea 

Tertiary 

care or 

university 

hospital 

10/1998 

– 

1/1999 

3.5 

months 

Hand hygiene 

Maximal sterile 

barrier 

precautions 

QI Strategies: Clinician education 

An intensive surveillance and catheter care 

education program was instituted at an ICU 

in Korea. The infection control committee 

held "Infection Control Week", during which 

new guidelines for central line care, aseptic 

technique, and hand washing were 

distributed. Infection control staff conducted 

daily surveillance of all central lines to 

monitor for appropriate catheter care, 

including hand washing, occlusive dressing, 

and aseptic application of povidone iodine. 

Infection control staff gave direct feedback if 

protocols were violated, and recommended 

catheter removal and blood cultures if the 

patient has symptoms of CLABSI. 

Infection rate 

prior to 

intervention: 

4.2 CLABSI 

per 1,000 

catheter-days 

Infection rate 

after 

intervention: 

1.3 CLABSI 

per 1,000 

catheter-days 

p=NS 

Frankel, 

200597 United 

States 

Tertiary 

care or 

university 

hospital 

5/2001 

- 

5/2002 

2 years Maximal sterile 

barrier 

precautions 

QI Strategies: Clinician education, audit and 

feedback, organizational change 

The study used Six Sigma methods to reduce 

CLABSI in a surgical ICU. Trained facilitators 

met with clinical stakeholders to instruct them 

in Six Sigma methodology, which focus on 

minimizing variability and improving 

efficiency. The stakeholder groups (SICU 

staff and hospital epidemiologists) 

determined risk factors for CLABSI and 

formulated a stepwise intervention. This 

consisted of a standardized video tutorial for 

residents on insertion site practices, 

development of new policies for changing 

catheters over wires, development of a 

standardized kit with insertion materials, new 

policies for catheter care, and inserting 

antibiotic-coated catheters in patients 

expected to be ventilated for >4 days. Also, 

all central lines were inserted under direct 

supervision of an attending physician except 

in an emergency. Feedback on infection 

rates was posted in the ICU. 

CLABSI rate: 

Infection rate 

before 

intervention: 

10.5/1,000 

catheter-days 

After 

intervention: 

1.7/1,000 

catheter-days 

p<0.001 
66

Before-After Studies With Poor Internal and External Validity. We identified seven simple 

before-after studies with poor internal and external validity which are listed in Table 6e. One of 

these60 will be discussed under the section addressing prevention of VAP. 

Table 6e. Articles addressing prevention of central line-associated bloodstream infections: simple beforeafter studies of poor methodologic quality 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results 

Bijma 

199998 The 

Netherla

nds 

Tertiary 

care or 

university 

hospital 

Not 

specified 

6 

months 

Hand hygiene QI Strategies: Clinician education; 

organizational change 

The following fivefold intervention was 

consecutively implemented during a 12-

month period: 

1. A propanol/isopropanol solution 

containing a quaternary ammonium 

compound and an emollient to prevent 

excessive drying of the skin was 

introduced as a hand disinfecting agent. 

2. An adhesive, non-woven, island-type 

gauze was introduced as CVC dressing. 

3. A “one bag” TPN system was 

introduced. 

4. A small needleless closed IV 

connection device was incorporated in 

every SICU patient’s IV system. 

5. Implementation of the aforementioned 

measures was carried out by and under 

continuous surveillance of the SICU’s 

infection control practitioner (ICP). 

Checking protocol compliance required 

the ICP’s daily presence on the SICU. 

Infection rate 

prior to 

intervention: 

15.0 CLABSI 

per 1,000 

catheter-days 

Infection rate 

after 

intervention: 

8.0 CLABSI per 

1,000 catheterdays 

P=NS 

*Lam 

200462 Hong 

Kong 

Tertiary 

care or 

university 

hospital 

Not 

specified 

10 

months 

Hand hygiene QI Strategies: Clinician reminder; 

organizational change 

Nurses and physicians received an 

educational program targeting hand 

hygiene. A hand hygiene protocol was 

implemented as part of the orientation for 

new staff. Face-to-face educational 

seminars were conducted for nurses and 

physicians where solutions to overcome 

obstacles to hand washing were provided; 

2 sessions were provided for physicians 

and 10 for nurses. A task-oriented 

analysis was performed to identify 

strategies for hand washing during 

complex procedures. Demonstrations 

were conducted at regular intervals, and 

reminder pictures were posted at each 

hand washing basin. 

Infection rate 

prior to 

intervention: 

6.8 CLABSI per 

1,000 catheterdays 

Infection rate 

after 

intervention: 

1.2 CLABSI per 

1,000 catheterdays 

p=NS 

Compliance 

with hand 

hygiene: 

Before 

intervention: 

40% 

After 

intervention: 

53% 

p<0.01 
67

Table 6e. Articles addressing prevention of central line-associated bloodstream infections: simple before-after studies 

of poor methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length of 

follow-up 

Preventive 

Interventions 

Quality improvement intervention Results 

Lobo 

2005101 Brazil 

Tertiary 

care or 

university 

hospital 

1/01 

through 

12/02 

20 months Hand hygiene 

Maximal sterile 

barrier 

precautions 

QI Strategies: Clinician education; 

audit and feedback, clinician 

reminder 

An education program was 

developed by a multidisciplinary task 

force focusing on CVC insertion, 

manipulation, and care. 3 infection 

control nurses, a physician, and the 

entire unit staff were on the task 

force. 

Infection rate 

prior to 

intervention: 20 

CLABSI per 

1,000 catheterdays 

Infection rate 

after intervention: 

11 CLABSI per 

1,000 catheterdays 

p value not 

reported 

Adherence to 

appropriate use 

of maximal sterile 

barrier 

precautions: 

Before 

intervention: 91% 

after intervention: 

100% 

p=NS 

Penne 

200290 United 

States 

Tertiary 

care or 

university 

hospital 

January 

1997-

July 

1998, 

August 

1998-

March 

2000 

Not 

specified 

Hand hygiene 

Maximal sterile 

barrier 

precautions 

QI Strategies: Clinician education; 

audit and feedback; clinician 

reminder; organizational change 

A nurse educator performed 

individual education sessions with 

each staff member and demonstrated 

dressing change to ensure sterile 

technique and proper application of 

dressing to prevent risk of infection 

Number of 

CLABSI before 

intervention: 39 

Number of 

CLABSI after 

intervention: 24 

Note: number of 

catheter-days not 

supplied 

Puntis 

1991104 UK 

Not 

specified 

Not 

specified 

Not 

specified 

Hand hygiene QI Strategies: Clinician education 

The nutritional care team at a 

children's hospital instituted an 

education program for care of 

catheters used for parenteral 

nutrition. Hand hygiene was 

emphasized, and new guidelines for 

catheter care were drawn up 

emphasizing use of aseptic technique 

and proper technique for changing 

feeding bags. Demonstrations of line 

care and bag changing were 

organized for nursing staff at which 

attendance was compulsory. A video 

of proper technique was also shown. 

This educational intervention was 

delivered to junior medical staff and 

nurses. 

Infection rate 

prior to 

intervention: 45% 

of catheters 

infected 

Infection rate 

after intervention: 

8% of catheters 

infected 
68

Table 6e. Articles addressing prevention of central line-associated bloodstream infections: simple before-after studies 

of poor methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length of 

follow-up 

Preventive 

Interventions 

Quality improvement intervention Results 

Rosenthal 

2003102 Argentin

a 

Nonteaching 

communi

ty 

hospital 

Bernal 

Medical 

center: 

4/1999-

5/1999; 

Colegiale

s 

Medical 

Center, 

9/2000-

12/2000 

22 months Hand hygiene 

Maximal sterile 

barrier 

precautions 

Appropriate 

insertion site 

selection 

Prompt 

removal of 

unnecessary 

catheters 

QI Strategies: Clinician education; 

audit and feedback 

A surveillance and educational 

intervention was implemented at 2 

ICUs in Argentina. Health care 

workers in the study ICUs underwent 

training for central venous catheter 

care based on CDC guidelines (at the 

time, these included hand hygiene, 

maximal sterile barrier precautions, 

appropriate insertion site selection 

and prompt removal of unnecessary 

catheters; however, chlorhexidine 

skin sterilization was not part of the 

guidelines.) Subsequently, 

performance feedback on catheter 

site care was provided to the ICU 

staff on a monthly basis. Compliance 

rates with catheter care were also 

provided to ICU administrators. This 

intervention was referred to as phase 

2 (phase 1 being the pre-intervention 

period.) A separate intervention to 

encourage hand washing was 

implemented simultaneously; all 

health care workers received a 

comprehensive infection control 

manual. Hand washing compliance 

was observed covertly in the ICU by 

an infection control practitioner and 

monthly meetings were held at which 

hand washing rates were displayed 

and fed back to providers. Hand 

washing rates were also posted 

monthly in the ICUs and reported to 

the ICU manager and administrator. 

The hand washing guideline was also 

posted in the ICU. Educational 

classes were given in 1-hour group 

sessions for each shift daily for 1 

week (attendance was voluntary). 

Participants underwent a posttest to 

evaluate retention of the educational 

material. In addition, infection control 

review classes were held to answer 

questions and share surveillance 

data. 

Infection rate 

prior to 

intervention: 

45.94 CLABSI 

per 1,000 

catheter-days 

Infection rate 

after intervention: 

9.90 CLABSI per 

1,000 catheterdays 

p<0.01 

Adherence to 

protocols for hand 

hygiene before 

intervention: 

23.1% 

after intervention: 

64.5% 

p<0.01 
69

Table 6e. Articles addressing prevention of central line-associated bloodstream infections: simple before-after studies 

of poor methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length of 

follow-up 

Preventive 

Interventions 

Quality improvement intervention Results 

Wall 

200595 United 

States 

Tertiary 

care or 

university 

hospital 

began 

11/2002 

2 years Hand hygiene 

Maximal sterile 

barrier 

precautions 

Chlorhexidine 

skin 

sterilization 

QI Strategies: Clinician education; 

audit and feedback 

A continuous quality improvement 

intervention was conducted in a 

medical intensive care unit. An 

interdisciplinary team consisting of 

the MICU director and nurse 

manager, MICU nurses and 

physicians, epidemiologist, infection 

control practitioner and QI experts 

was assembled and decided to focus 

on central line insertion practices 

(after reviewing relevant prevention 

literature). The intervention primarily 

targeted house staff physicians. A 

nurse observed central line insertions 

to determine the baseline quality gap. 

A checklist for central line insertion 

was developed that mandated: hand 

hygiene, maximal sterile barrier 

precautions, chlorhexidine skin 

preparation, and proper supervision 

of trainees. (These steps could be 

skipped if the insertion was 

considered an emergency.) 

Providers were educated on the 

checklist and supporting evidence 

through a web-based tutorial with 

self-assessment exam; house staff 

was required to complete the tutorial. 

Infection rates and rates of 

compliance with process measures 

were fed back to the front line staff. 

Infection rate 

prior to 

intervention: 7.0 

CLABSI per 

1,000 catheterdays 

Infection rate 

after intervention: 

3.8 CLABSI per 

1,000 catheterdays 
70

Table 6e. Articles addressing prevention of central line-associated bloodstream infections: simple before-after studies 

of poor methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length of 

follow-up 

Preventive 

Interventions 

Quality improvement intervention Results 

**Berg 

199560 Guatema

la 

Tertiary 

care or 

university 

hospital 

3 months 1 year Hand hygiene QI Strategies: Clinician education 

A multifaceted intervention was used 

to target nosocomial infections in the 

ICU, with both general measures and 

measures targeting VAP and CA-UTI. 

Nurses and physicians received 15 

educational sessions on aseptic 

technique, stressing proper hand 

washing. The educational sessions 

used lectures and demonstrations, 

and individual clinicians also received 

positive and negative feedback and 

reminder signs at the bedside. The 

VAP intervention targeted proper use 

of sterile rinse water and 

improvement in aseptic technique for 

suctioning. Providers received more 

than 15 interactive conferences on 

the detection, management, and 

prevention of nosocomial pneumonia; 

these included lectures, 

demonstrations, individual instruction 

and feedback, and contests. The 

CA-UTI intervention consisted of 

changing open urinary drainage 

systems to closed systems (aseptic 

catheter care), with an educational 

session on the new catheter. The 

intervention did not specifically target 

surgical site infections, but those 

outcomes are reported. 

Infection rate 

prior to 

intervention: 14% 

of patients 

Infection rate 

after intervention: 

13% of patients 

p=NS 

Adherence to 

protocols for hand 

hygiene: 

before 

intervention: 5% 

after intervention: 

63% 

p<0.01 

*This study addresses prevention of central line-associated bloodstream infections and ventilator-associated pneumonia. 

**This study addresses prevention of surgical site infections, central line-associated bloodstream infections, ventilator-associated 

pneumonia and catheter-associated urinary tract infections. 
71

Table 7. Quality criteria for simple before-after studies addressing central line-associated bloodstream 

infections 

Internal Validity External Validity 

Author Did the study 

report data on 

more than one 

time point before 

and after the 

intervention? 

If the study 

reported infection 

rates, did it also 

report process 

measurements? 

Was the 

intervention 

performed 

independent of 

other QI efforts 

or other 

changes? 

Did the study 

use NNIS/CDC 

methods for 

measuring 

infections? 

Did the study 

report infection 

rates in 

terms of device 

utilization? 

Berg 199560 ○ ● ▲ ● ●

Bijma 199998 ○ ○ ▲ ○ ●

Coopersmith 

200288 ● ○ ● ● ●

Coopersmith 

200489 ● ● ▲ ● ●

Frankel, 200597 ● ○ ○ ● ●

Higuera 2005100 ● ● ● ● ●

Lobo 2005101 ○ ● ● ● ●

Lam 200462 ○ ○ ▲ ● ●

Penne 200290 ○ ● ▲ ○ ○

Puntis 1991104 ○ ○ ▲ ● ○

Rosenthal 2003102 ○ ○ ○ ● ○

Sheretz 200091 ● ● ▲ ● ●

Wall 200595 ● ○ ▲ ○ ●

Warren 200392 ○ ● ● ● ●

Warren 200493 ● ● ▲ ● ●

Yoo 2001103 ○ ● ● ● ●

●: Yes ○: No ▲: Unclear

Ventilator-Associated Pneumonia 

Included Studies: Settings, Goals, and Target Populations 

Our search strategy identified a total of 12 articles meeting our inclusion criteria that assessed 

prevention of ventilator-associated pneumonia (Tables 8a-8c). Of these, ten specifically targeted 

VAP, and two60, 62 addressed prevention of multiple types of HAIs including VAP. Studies were 

mostly performed in the United States.107-114 Ten studies took place in a single institution and 

two107, 113 in multiple hospitals. Studies primarily evaluated prevention of VAP in adult medicalsurgical ICUs;60, 107-111, 114-116 results were reported separately for medical and surgical patients in 

two studies.109, 110 One study62 was conducted in a neonatal ICU and one study107 evaluated an 

intervention conducted in both adult and pediatric ICUs. Six107, 109, 110, 113, 115, 116 of the nine 

studies reporting the study period were conducted within the last decade. The follow-up periods 

ranged from six months to 2.5 years, with a median of one year. The median baseline rate of 

VAP was 19.5 per 1,000 ventilator-days, but varied widely across the studies (range 5.5 – 113 
72

episodes/1,000 ventilator-days.) By comparison, the median rate of VAP in medical-surgical 

ICUs at NNIS hospitals in 2003 was 4.6 per 1,000 ventilator days (interquartile range, 2.6 – 7.2) 

for major teaching hospitals and 5.6 per 1,000 ventilator-days at all other hospitals (IQR 

2.9 – 6.7).14

Preventive Interventions and Outcomes Measured 

We identified hand hygiene, semirecumbent patient positioning, and daily interruption of 

sedation and assessment of readiness to wean as target preventive interventions for this review. 

All included studies explicitly promoted hand hygiene, and eight107-111, 113-115 promoted 

semirecumbent patient positioning; two studies107, 113 promoted daily assessment of readiness to 

wean from the ventilator. Overall, many other preventive interventions were used in the studies 

(Table 9). 

Aseptic drainage of ventilator circuit condensate, appropriate suctioning technique, and 

provision of oral care (including chlorhexidine mouthwash) were frequently incorporated into 

preventive strategies. Some studies made use of interventions that remain controversial, such as 

universal peptic ulcer disease prophylaxis113 or use of heat and moisture exchangers.107, 111, 115 

All studies focused specifically on prevention of VAP and instituted preventive interventions 

targeting it, with the exception of one study62 which implemented an intervention targeting hand 

hygiene and measured its effects on multiple HAIs in an ICU. 

Quality Improvement Strategies 

All studies primarily used educational interventions targeted at providers (Tables 8a-8c). 

Nurses and physicians were specifically targeted in all 12 studies, and respiratory therapists in 

six;107, 108, 110, 111, 115, 116 three studies60, 113, 116 targeted all clinical staff in the ICU. Most studies 

combined use of written materials and lectures, with six studies60, 107, 108, 111, 113, 115 using an 

explicit clinical guideline for preventive care. Three studies109, 111, 116 used audit and feedback of 

infection rates to ICU staff or ICU managers, and two108, 112 used a continuous quality 

improvement intervention. One113 incorporated other organizational change strategies 

(establishment of multidisciplinary team rounds daily and daily assessment of patient goals on 

rounds). No other QI strategies were used in any included study. 

Methodologic Quality of Included Studies 

The methodologic quality of studies was generally poor, as all used a quasi-experimental, 

before-after design (Tables 8a-8c). With this limitation, the external validity of studies was 

generally good, as all but one110 used CDC/NNIS definitions to diagnose VAP and all reported 

infection rates adjusted for device utilization (Table 10). However, the studies exhibited 

limitations with internal validity. Only five studies107, 108, 110, 111, 115 reported infection rates at 

more than one time point before and after the intervention, and only two studies107, 109

specifically stated that no other QI interventions took place contemporaneously. Three studies60, 

62, 111 reported both infection rates and process measures (in each case, compliance with hand 

hygiene protocols), and one study114 measured only process measures (adherence to 

semirecumbent patient positioning). Because of the lack of controlled studies, variety of 
73

preventive interventions used, and the wide differences in baseline rates of VAP, we did not 

attempt quantitative synthesis of the results. Given the generally poor methodologic quality of 

the results and the homogeneity of QI strategies used, we will summarize the studies that we 

considered to have generally stronger internal and external validity. 

Before-After Studies With Good Internal and External Validity. Two studies107, 110

conducted within the same integrated health system used an educational intervention centered 

around a self-study module for physicians, nurses and respiratory therapists (Table 8a). The 

paper-based module consisted of a comprehensive tutorial on the epidemiology, risk factors, 

diagnosis, and prevention of VAP, accompanied by a 20-question pretest and posttest. The 

preventive interventions discussed included semirecumbent patient positioning and hand 

hygiene. Completion of the module and passing the post-test was required for all respiratory 

care practitioners (RCPs) in one study110 and was strongly encouraged for nurses in both studies. 

Of note, both of these studies documented the reach of the intervention by documenting the 

percentage of nurses and RCPs completing the module. These studies were both of similar 

methodologic quality, with good external validity; both studies also reported data at more than 

three time points before and after the intervention, but did not conduct a formal time series 

statistical analysis. One study110 used the American College of Chest Physicians diagnostic 

criteria for VAP rather than the NNIS definition, but as the ACCP criteria are slightly more 

stringent, it is unlikely that this affects the applicability of the results significantly. Results 

revealed a statistically significant decrease in the incidence of VAP in three of the four hospitals 

evaluated in the two studies (one community hospital, one adult tertiary care hospital and one 

pediatric tertiary care hospital). Another community hospital failed to note a decrease in VAP 

rates but also had the lowest rate of completion of the module among RCPs. The baseline rates 

of VAP were lower than other included studies (8.75/1,000 ventilator days and 12.6/1,000 

ventilator days respectively), but still above the pooled NNIS median during that time period. 

An educational intervention targeting semirecumbent patient positioning was carried out in 

another study at a tertiary care hospital.114 The study used a multifaceted intervention using 

clinician reminders (incorporating an order for semirecumbent positioning into standardized 

order sets) and interactive education for physicians and nurses; adherence was measured at 

baseline and at two and six months after the intervention. As VAP rate was not measured, we 

could not fully apply our study quality criteria. The study achieved a statistically significant 

improvement in the proportion of patients with the head of the bed elevated above 30 degrees 

(from 26 percent pre-intervention to 88 percent post-intervention.) 
74

Table 8a. Articles addressing prevention of ventilator-associated pneumonia: simple before-after studies of 

good methodologic quality 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

Babcock 

2004107 United 

States 

Multiple 

hospitals 

of 

different 

types 

(1 adult 

tertiary 

care, 1 

pediatric 

tertiary 

care, 2 

community 

hospitals) 

1/2000-

1/2001 

18 

months 

Hand hygiene 

Head of bed 

elevation 

above 30 

degrees 

Daily 

interruption of 

sedation 

QI Strategies: Clinician education 

All nurses and respiratory care practitioners 

working in the ICU at 4 hospitals received a 

self-study module on preventing VAP, 

accompanied by pre- and post-test 

examinations. The self-study module 

contained information on the epidemiology, 

risk factors, clinical and economic 

consequences, etiology, definitions, diagnostic 

procedures, and risk reduction methods for 

VAP. All participants had to complete the 

module and score >80% on the post-test. The 

module was mandated for nurses at 3 of the 4 

hospitals. The key messages were also used 

in posters and fact sheets in the ICU. Nursing 

and respiratory care staff also underwent inservice training (at scheduled training times 

and staff meetings). At the adult teaching 

hospital, respiratory care practitioners 

received 2 1-hr lectures on VAP. 

Infection rate 

prior to 

intervention: 

8.75 VAP per 

1,000 

ventilatordays 

Infection rate 

after 

intervention: 

4.74 VAP per 

1,000 

ventilatordays 

p<0.01 
75

Table 8a. Articles addressing prevention of ventilator-associated pneumonia: simple before-after studies of good 

methodologic quality (continued)

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

Zack 

2002110 United 

States 

Tertiary 

care or 

university 

hospital 

10/2000 

 - 

 9/2001 

1 year Head of bed 

elevation 

above 30 

degrees 

QI Strategies: Clinician education 

ICU nurses and respiratory therapists 

received an educational intervention 

targeting VAP prevention. Participants 

completed a 10-page self-study module with 

information on the epidemiology, risk factors, 

etiology, diagnosis, consequences, and 

prevention of VAP. The specific preventive 

interventions included: head of bed 

elevation >30 degrees, encouraging 

orotracheal intubation and orogastric tubes, 

early extubation and use of NIV when 

needed, provision of adequate sedation, 

avoidance of gastric over distention, 

provision of oral hygiene, avoiding overuse 

of antibiotics, and appropriate disposal of 

ventilator circuit condensates. Participants 

were required to complete a 20 question 

pretest and posttest before and after 

completing the educational module. 

Infection control practitioners also conducted 

in-services at scheduled meeting times, and 

respiratory therapists also received two 1-

hour lectures on VAP. The RCPs completed 

the posttest again 6 months after completing 

the self-study module. The module was 

mandatory for all RCPs, but was not 

mandatory for nurses. Individuals who 

scored <80% on the posttest were required 

to repeat the module. Additionally, fact 

sheets and posters were posted in the ICU. 

Infection rate 

prior to 

intervention: 12.6 

VAP per 1,000 

ventilator days 

Infection rate 

after intervention: 

5.7 VAP per 

1,000 ventilator 

days 

p<0.01 

Helman 

2003114 United 

States 

Tertiary 

care or 

university 

hospital 

Not 

reported 

6 

months 

Head of bed 

elevation 

above 30 

degrees 

QI Strategies: Clinician education, clinician 

reminder 

An intervention to improve compliance with 

elevation of the head of the bed above 30 

degrees was carried out at a teaching 

hospital. The first intervention consisted of 

adding an order to the standardized 

admission order set to keep the HOB 

elevated. The second intervention (which 

took place 2 months after the first) was an 

educational intervention targeting all 

physicians and nurses. The educational 

session was a group discussion based on a 

prepared poster on HOB elevation. The 

session was mandatory for all physicians. 

Compliance to 

head of bed 

elevation > 30 

degrees: 

Compliance 

before 

intervention: 

26% 

After 

intervention: 

88% 

p<0.01
76

Before-After Studies With Moderate Internal and External Validity. A continuous quality 

improvement intervention was conducted in a study111 in a community hospital, focusing on 

hand hygiene and semirecumbent patient positioning. The study also used audit and feedback of 

VAP rates to practitioners (Table 8b). Although this study had reasonable internal validity, the 

applicability of its results is questionable. The study was conducted in 1989, and many aspects 

of ICU care have changed since then, as have VAP diagnostic criteria. Nevertheless, the study 

did document improvement in hand hygiene after the intervention as well as a reduction in VAP 

rates. 

A staggered educational intervention consisting of semirecumbent patient positioning and 

interventions targeting suctioning technique,109 along with audit and feedback of infection rates 

to staff, was also successful in reducing VAP rates in both a surgical and medical ICU in a 

tertiary care hospital (Table 8b). The study also conducted a cost analysis showing that nearly 

$350,000 was saved as a result of preventing a total of 66 episodes of VAP. However, only one 

time point of data was provided pre-intervention, limiting the internal validity of the results. 

A study conducted in two Argentinean ICUs116 used a brief educational intervention 

consisting of a 1-hour lecture to all ICU staff, along with implementation of a nosocomial 

infection surveillance system using NNIS methodology. The study also had a markedly high rate 

of VAP (51.3 episodes/1,000 ventilator-days) and did document a significant reduction. 

A prevention guideline recommending hand hygiene and semirecumbent patient positioning 

was disseminated in a study from Pakistan115 that used a focused educational intervention, but 

without use of a self-study module. This study was of good internal validity, also documenting 

infection rates at three time points before and after the intervention. The intervention was 

associated with a 51 percent relative decrease in the incidence of VAP, but the authors noted that 

an outbreak of Acinetobacter VAP took place immediately before implementation of the 

intervention. Thus, part of the observed results may have represented regression to the mean 

rather than a true intervention effect. 
77

Table 8b. Articles addressing prevention of ventilator-associated pneumonia: simple before-after studies of 

moderate methodologic quality 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

Kelleghan 

1993111 United 

States 

Communit

y hospital 

Spring 

1989-

Spring 

1990 

18 

months. 

Hand hygiene 

Head of bed 

elevation 

above 30 

degrees 

QI Strategies: Clinician education, 

audit and feedback, regulatory 

incentives 

A CQI-based intervention was 

performed by a multidisciplinary 

Nosocomial Pneumonia Prevention 

Team consisting of members from 

nursing, infection control, physicians, 

and respiratory care. The team 

developed a prevention guideline for 

nurses and RTs consisting of hand 

washing, HOB elevation, ventilator 

care (scheduled circuit changes, 

suction catheter changes etc), 

neurologic assessment, and oral 

care. The guideline was presented to 

RNs and RTs in educational 

meetings including feedback on 

infection rates and demonstrations 

using equipment and mannequins. 

Nurses received continuing education 

credit for attendance. Note, new 

equipment (heat and moisture 

exchangers) were also introduced 

after the educational campaign was 

completed. 

Infection rate 

prior to 

intervention: 17 

VAP per 1,000 

ventilator days 

Infection rate 

after intervention: 

5 VAP per 1,000 

ventilator days 

Adherence to 

protocols for hand 

hygiene: 

before 

intervention: 40% 

after intervention: 

58% 

p values not 

reported 

Lai 2003109 United 

States 

Tertiary 

care or 

university 

hospital 

Second 

quarter of 

1997 - 

First 

quarter of 

1998 

18 

months 

Head of bed 

elevation 

above 30 

degrees 

QI Strategies: Clinician education, 

audit and feedback 

A team consisting of the hospital 

epidemiologist, infection control 

practitioners, ICU directors and ICU 

managers developed and 

implemented preventive 

interventions. The interventions 

consisted of elevation of the head of 

the bed and changes in maintenance 

of nasogastric feeding tubes and 

prolongation of the time between 

changing of inline suction catheters. 

Infection rates were presented 

quarterly to ICU staff at staff 

meetings and via charts. 

Infection rate 

prior to 

intervention: 

Surgical ICU: 

45.1 VAP per 

1,000 ventilatordays; Medical 

ICU: 22.4 VAP 

per 100 

ventilator-days 

Infection rate 

after intervention: 

Surgical ICU: 

27.9 VAP per 100 

ventilator-days; 

Medical ICU: 

11.6 VAP per 100 

ventilator-days 

p values not 

supplied 
78

Table 8b. Articles addressing prevention of ventilator-associated pneumonia: simple before-after studies of moderate 

methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

Rosenthal 

2006116 Argentina 

Two nonteaching 

communit

y 

hospitals 

11/2001-

12/2002 

1 year Hand hygiene QI Strategies: Clinician education, 

audit and feedback 

All clinical staff received 1-hour 

educational sessions on VAP, 

discussing the epidemiology and 

pathogenesis, hand hygiene, proper 

handling of secretions and catheters, 

and percussion and postural drainage 

to stimulate coughing. Feedback of 

VAP rates was provided to ICU staff 

monthly at infection control meetings, 

and to ICU administrators. 

Infection rate 

prior to 

intervention: 

51.28 VAP per 

1,000 ventilator 

days 

Infection rate 

after 

intervention: 

35.52 VAP per 

1,000 ventilator 

days 

p<0.01 

Salahuddin 

2004115 Pakistan 

Tertiary 

care or 

university 

hospital 

1/2003-

12/2003 

1 year Hand hygiene 

Head of bed 

elevation 

above 30 

degrees 

QI Strategies: Clinician education 

A clinical guideline was developed for 

VAP prevention by physicians and the 

ICU head nurse. The elements of the 

guideline were: hand washing, 

protective gown/glove use for specific 

groups of patients, head of bed 

elevation >30 degrees, avoiding gastric 

over distension, use of NIPPV to avoid 

intubations and facilitate early 

extubation, use of OG tubes instead of 

NG tubes, provide adequate sedation, 

prevent accidental extubation, perform 

oral hygiene with chlorhexidine, and 

removal of inline humidifiers from 

ventilators. An educational program, 

based on the guideline, was 

administered to ICU nursing and junior 

medical staff through weekly lectures, 

departmental presentations, 

"reinforcement at the bedside and 

visual aids posted in the ICU." 

Infection rate 

prior to 

intervention: 

13.2 VAP per 

1,000 ventilator 

days 

Infection rate 

after 

intervention: 

6.5 VAP per 

1,000 ventilator 

days 

p=0.02 

Before-After Studies With Poor Internal and External Validity. Five studies met all our 

inclusion criteria, but had methodologic flaws that seriously limited the internal or external 

validity of the results (Table 8c).60, 62, 108, 113, 116 One study108 incorporated scheduled changes of 

the ventilator circuit as one of the main preventive interventions; this is explicitly discouraged by 

both the ATS/IDSA and CDC guidelines. Another113 restricted reporting of infection rates to 

studies that documented improvement in process outcomes. One study112 provided virtually no 

details on the QI intervention that was conducted. Finally, a study conducted in an ICU in 

Guatemala combined an educational intervention on hand hygiene with an intensive educational 

intervention focusing on aseptic suctioning technique.60 The hospital had no formal infection 

control mechanisms in place prior to the study and had a remarkably high baseline rate of VAP 

(113/1,000 ventilator-days). Although the rate was reduced substantially, it remained high 
79

(40/1,000 ventilator-days) post-intervention. The study did document markedly improved 

compliance with hand hygiene. The rates of other HAIs (CAUTI, SSI, and CLABSI) did not 

change. 

Table 8c. Articles addressing prevention of ventilator-associated pneumonia: simple before-after studies of 

poor methodologic quality 

Author Setting and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

*Berg 

199560

Guatemala 

Tertiary care 

or university 

hospital 

Not 

specifie

d 

1 year Hand hygiene QI Strategies: Clinician education 

A multifaceted intervention was used to 

target nosocomial infections in the ICU, with 

both general measures and measures 

targeting VAP and CAUTI. Nurses and 

physicians received 15 educational sessions 

on aseptic technique, stressing proper hand 

washing. The educational sessions used 

lectures and demonstrations, and individual 

clinicians also received positive and 

negative feedback and reminder signs at the 

bedside. The VAP intervention targeted 

proper use of sterile rinse water and 

improvement in aseptic technique for 

suctioning. Providers received more than 

15 interactive conferences on the detection, 

management, and prevention of nosocomial 

pneumonia; these included lectures, 

demonstrations, individual instruction and 

feedback, and contests. The CAUTI 

intervention consisted of changing open 

urinary drainage systems to closed systems 

(aseptic catheter care), with an educational 

session on the new catheter. The 

intervention did not specifically target 

surgical site infections, but those outcomes 

are reported. 

Infection rate 

prior to 

intervention: 

113 VAP per 

1,000 

ventilatordays 

Infection rate 

after 

intervention: 

40 VAP per 

1,000 

ventilatordays 

p<0.01 

Adherence to 

protocols for 

hand 

hygiene: 

Before 

intervention: 

5% 

After 

intervention: 

63% 

p<0.01 

Joiner 

1996108 United 

States 

Tertiary care 

or university 

hospital 

5/1992-

9/1992 

2.5 

years 

Hand hygiene 

Head of bed 

elevation 

above 30 

degrees 

QI Strategies: Clinician education, 

organizational change 

A QI team (including physicians, respiratory 

therapists, ICU nurses, infection control 

practitioners, and quality managers) 

brainstormed to develop practice guidelines 

for preventing VAP. These guidelines were 

developed into a standardized protocol and 

presented to staff in a presentation and at 

staff meetings. VAP rates were reviewed 

monthly and shared with departments. A 

continuous quality improvement method 

was used to review data and revise the 

intervention as needed. 

Infection rate 

prior to 

intervention: 

26 VAP per 

1,000 

ventilatordays 

Infection rate 

after 

intervention: 

16 VAP per 

1,000 

ventilatordays 

p value not 

reported 
80

Table 8c. Articles addressing prevention of ventilator-associated pneumonia: simple before-after studies of poor 

methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventio

ns 

Quality improvement intervention Results

Resar 

2005113 United 

States 

Multiple 

hospitals 

of 

different 

types 

2002-

2004 

6 

months 

Head of bed 

elevation 

above 30 

degrees 

Daily 

interruption 

of sedation 

QI Strategies: Clinician education, 

organizational change 

Report of 61 hospitals who participated in 

the IHI IMPACT network. Teams of 

critical care physicians from each 

organization attended collaborative 

meetings, beginning with a half-day 

introductory course on change concepts. 

The "ventilator bundle", consisting of PUD 

prophylaxis, DVT prophylaxis, HOB 

elevation, and sedation vacation, were the 

key concepts targeted for implementation, 

and the collaborative meetings sere 

devoted to implementation methods. 

ICU’s implemented multidisciplinary 

rounds and daily patient goals at a 

minimum. 

For medicalsurgical ICUs 

Infection rate 

prior to 

intervention: 5.5 

VAP per 1,000 

ventilator days 

Infection rate 

after intervention: 

2.7 VAP per 

1,000 ventilator 

days 

p value not 

reported 

Nicotra 

1996112 United 

States 

Single 

hospital, 

type not 

specified 

12/1991-

5/1994 

18 

months 

Hand 

hygiene 

QI Strategies: Clinician education, 

organizational change 

A continuous quality improvement style 

intervention was implemented to reduce 

VAP. A multidisciplinary task force 

developed a process improvement plan 

consisting of implementation of a closed 

suction device, and changes in cleaning 

and maintenance of ventilator units. A 

survey was performed which revealed a 

lack of knowledge among nurses about 

preventive interventions for VAP. Thus, 

an educational program on VAP was 

conducted for nurses, consisting of 

information about hand washing, 

suctioning, other preventive measures 

(such as patient mobilization, respiratory 

care, maintaining hydration, assessing 

nutritional status, and review of drugs for 

stress ulceration), as well as general 

infection control measures. 

Infection rate 

prior to 

intervention: 22 

VAP per 1,000 

ventilator days 

Infection rate 

after intervention: 

8.3 VAP per 

1,000 ventilator 

days 

p values not 

reported 

 
81

Table 8c. Articles addressing prevention of ventilator-associated pneumonia: simple before-after studies of poor 

methodologic quality (continued)

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventio

ns 

Quality improvement intervention Results

**Lam 

200462 Hong 

Kong 

Tertiary 

care or 

university 

hospital 

Not 

specified 

10 

months 

Hand 

hygiene 

QI Strategies: Clinician reminder; 

organizational change 

Nurses and physicians received an 

educational program targeting hand 

hygiene. A hand hygiene protocol was 

implemented as part of the orientation for 

new staff. Face-to-face educational 

seminars were conducted for nurses and 

physicians where solutions to overcome 

obstacles to hand washing were provided; 

2 sessions were provided for physicians 

and 10 for nurses. A task-oriented 

analysis was performed to identify 

strategies for hand washing during 

complex procedures. Demonstrations 

were conducted at regular intervals, and 

reminder pictures were posted at each 

hand washing basin. 

Infection rate 

prior to 

intervention: 16.9 

VAP per 1,000 

ventilator days 

Infection rate 

after intervention: 

6.4 VAP per 

1,000 ventilator 

days 

p=NS 

Adherence to 

protocols for hand 

hygiene: 

before 

intervention: 40% 

after intervention: 

53% 

p<0.01 

*This study addresses prevention of surgical site infections, central line-associated bloodstream infections, ventilator-associated 

pneumonia and catheter-associated urinary tract infections. 

**This study addresses prevention of central line-associated bloodstream infections and ventilator-associated pneumonia.
82

Table 9. Other preventive interventions used in studies addressing ventilator-associated pneumonia 

Author Continuous 

aspiration of 

subglottic 

secretions 

Avoidance of 

scheduled 

ventilator 

circuit 

changes 

Use of heat 

and 

moisture 

exchangers 

Universal 

peptic ulcer 

disease 

prophylaxis 

Aseptic 

suctioning 

technique 

Aseptic 

drainage of 

ventilator 

circuit 

condensate 

Oral 

care 

O

Babcock 2004107 ○ ● ●* ○ ● ● ● Avoid gastric 

immunizations pneumococcu

Berg 199560 ○ ○ ○ ○ ● ● ○

Joiner 1996108 ○ ○ ○ ○ ● ● ●

Lai 2003109

○ ○ ○ ○ ○ ○ ○

Replacement ofor nasogastric line suction catevery 24 hours

Lam 200462 ○ ○ ○ ○ ○ ○ ○

Salahuddin 

2004115

○ ○ ● ○ ○ ○ ●

Monitor gastric noninvasive po(NIPPV) to avoextubation; use 

Zack 2002110

○ ○ ○ ○ ○ ● ●

Use orogastric overdistensionprovide immunpneumococcus

Kelleghan 

1993111 ○ ○ ● ○ ● ● ● Avoid gastric o

Nicotra 1996112 ○ ○ ○ ○ ▲* ▲* ○

Resar 2005113 ○ ○ ○ ● ○ ○ ○ Multidisciplinar

goals; DVT pro

Rosenthal 

2006116 ○ ○ ○ ○ ● ● ○ Percussion and 

coughing

●: Yes ○: No ▲: Unclear 

* - Babcock 2004107: heat and moisture exchangers contraindicated in patients with “excessive secretions”, but otherwise recommende

* - Nicotra 1996112: nurses “received information” on suctioning and handling of ventilator tubing, but does not specifically state that a

discussed.
83

Table 10. Quality criteria for simple before-after studies addressing ventilator-associated pneumonia 

Internal Validity External Validity 

Author Did the study 

report data on 

more than one time 

point before and 

after the 

intervention? 

If the study 

reported infection 

rates, did it also 

report process 

measurements? 

Was the 

intervention 

performed 

independent of 

other QI efforts or 

other changes? 

Did the study 

use NNIS/CDC 

methods for 

measuring 

infections? 

Did the study 

report infection 

rates in 

terms of device 

utilization? 

Babcock 

2004107 ● ○ ● ● ●

Berg 199560 ○ ● ▲ ● ●

Helman, 

2003114 ○ Not applicable ● Not applicable Not applicable 

Joiner 

1996108 ● ○ ▲ ● ●

Lai 2003109 ○ ○ ● ● ●

Lam 200462 ○ ● ▲ ● ●

Salahuddin 

2004115 ● ○ ▲ ● ●

Zack 2002110 ● ○ ▲ ○* ●

Kelleghan 

1993111 ● ● ▲ ● ●

Nicotra 

1996112 ○ ○ ▲ ● ●

Resar 

2005113 ○ ○ ▲ ▲† ●

Rosenthal 

2006116 ○ ○ ▲ ● ●

●: Yes ○: No ▲: Unclear 

* - The study used the American College of Chest Physicians criteria for diagnosis of VAP.

†

 - 84% of participating hospitals used CDC/NNIS definitions for measuring VAP rates. The methods used by the remaining 

hospitals were not specified. 
84

Catheter-Associated Urinary Tract Infection 

Included Studies: Settings, Goals, and Target Populations 

Our search identified ten articles that addressed prevention of catheter-associated urinary 

tract infections (Tables 11a-11e). All explicitly sought to reduce the incidence of CAUTI and/or 

reduce unnecessary urethral catheterization, with the exception of one study (discussed 

previously60 in the VAP section) that introduced a hand hygiene intervention and reported its 

effects on VAP, SSI, and CAUTI. Six of ten included studies60, 61, 117-120 were performed outside 

the U.S. An equal number of studies targeted CAUTI in ICU patients60, 61, 119-121 and general 

inpatient ward patients.117, 118, 122-124 All studies targeted adult patients. The baseline rate of 

CAUTI varied from 10.3 to 36 UTI per 1,000 urethral catheter-days (median, 15.1/1,000 

catheter-days). By comparison, the NNIS mean for medical-surgical ICUs in 2003 was 3.3 

CAUTI per 1,000 catheter-days (IQR 2.1 – 5.2/1,000 catheter-days) in major teaching hospitals 

and 3.1 (IQR 1.6 – 5.1) per 1,000 catheter-days in non-teaching hospitals. 

Preventive Interventions and Measured Outcomes 

We identified reduction in unnecessary catheter use, aseptic insertion and catheter care, and 

hand hygiene as key preventive interventions for CAUTI. Of the included studies, six118, 119, 121-

124 explicitly addressed reduction in placement of catheters or removal of unnecessary catheters 

once already placed, four61, 117, 120, 121 addressed aseptic insertion and catheter care, and two60, 120

hand hygiene. Among the four studies addressing insertion and catheter care, three117, 120, 121

implemented specific guidelines for catheter care after insertion, and one121 addressed catheter 

insertion technique. 

The measured outcomes varied across studies. Seven studies measured CAUTI rate, 

measured as rate of symptomatic CAUTI in six studies60, 61, 119-122 and asymptomatic bacteriuria 

in one.123 Five studies measured catheter usage,118, 119, 122-124 reported as the percentage of 

inpatients catheterized in three studies118, 122, 124 and the average duration of catheterization in 

two others.119, 123 Two studies, both of which implemented a catheter care policy117, 120 reported 

the rate of adherence to the policy (Tables 11a-11e). 

Quality Improvement Strategies 

Provider reminders were used in six studies,61, 118, 119, 122-124 all of which sought to reduce 

unnecessary catheter use through a printed61, 118, 119, 122 or computerized123, 124 reminder to 

physicians (Tables 11a-11e). Six studies60, 61, 117, 120-122 used provider education, specifically 

targeting nurses in one study117 and all clinical staff in the others. Two studies61, 120 used audit 

and feedback and two121, 122 used an organizational change strategy by allowing nurses to remove 

urethral catheters without a physician order. 

Methodologic Quality of Included Studies 

We identified three controlled before-after (CBA) studies117, 123, 124 and seven simple beforeafter studies.60, 61, 118-122 The CBA studies were generally of fair methodologic quality. With 
85

regards to factors affecting internal validity, the rationale for selection of the control group was 

not explained in any of the three studies, and no study reported if outcomes assessors were 

blinded to treatment group assignment. None of these studies reported CAUTI rate as a primary 

outcome, instead focusing on process measures (duration of urethral catheterization in two 

studies123, 124 and adherence to a guideline for urethral catheterization in one117). This likely 

serves to increase their external validity, given the inherent difficulty in comparing CAUTI rates 

between hospitals. 

The methodologic quality of the SBA studies was moderate within the limits of the study 

design. All studies reporting infection rates reported rates (Table 12) adjusted for device 

utilization, and all but one61 used NNIS definitions. However, only two studies reported data at 

more than one time point before and after the intervention61, 121 and three of seven studies 

reporting infection rates60, 119, 120 reported process measures as well. 

We will separately discuss the results of the studies addressing reduction in catheter usage 

and the studies addressing catheter care. 

Studies Addressing Reduction in Catheter Usage 

Seven studies61, 118, 119, 121-124 sought to reduce urethral catheter usage, 5118, 119, 122-124 through 

use of a paper- or computer-based reminder to clinicians (Table 11a). Two123, 124 were controlled 

studies and five61, 118, 119, 121, 122 were simple before-after studies. 

Reminders incorporated into an existing computerized physician order entry system were 

used in two studies,122, 123 one CBA123 and one SBA.122 In a controlled crossover trial at an 

academic medical center,123 the intervention consisted of a computerized order requiring an 

indication for catheter placement and a default 72-hour stop date for the catheter. The 

intervention successfully reduced the duration of catheterization on the study ward, but was not 

powered to detect a difference in CAUTI. A similar CPOE reminder with a 48-hour automatic 

stop date was used in another study,122 but in addition, nurses were empowered to discontinue 

catheters independent of a physician order according to a prespecified protocol. Significant 

reductions in both catheter use and CAUTI rates were demonstrated, albeit in the setting of a 

relatively high baseline rate of CAUTI (36/1,000 catheter-days.) 

Three studies118, 119, 124 used a paper-based reminder. A controlled trial124 used a chart 

prompt to physicians after a catheter had been in place for 48 hours, asking for a specific clinical 

indication to continue catheterization. Although hampered by initial implementation problems, 

the study did significantly reduce the percentage of days patients were catheterized compared to 

control. There was no difference in the need for urethral re-catheterization after catheter removal 

between intervention and control groups. A similar indication sheet was used in another beforeafter study118 requiring documentation of the indication for catheterization before it could be 

placed, but this failed to reduce the overall rate of catheterization. Nurses were required to 

remind physicians to remove unnecessary catheters five days after insertion in a before-after 

study;119 this intervention significantly reduced both the mean duration of catheterization and 

CAUTI rates in ICU patients. 

Finally, one study121 conducted in ICU patients empowered nurses to remove catheters 

without a physician order if prespecified indications were met. Nurses also received an 

educational intervention on catheter care. The intervention reduced CAUTI rates in all three 

ICUs studied. 
86

Table 11a. Articles addressing prevention of catheter-associated urinary tract infections (studies addressing 

reduction in catheter usage): controlled studies 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

Cornia 

2003123 United 

States 

Tertiary 

care or 

university 

hospital 

11/2000 

- 

3/2001 

8 

weeks 

Removal of 

unnecessary 

catheters 

QI Strategies: Clinician reminder 

Resident physicians were required to 

enter an order for urinary catheter 

placement in the hospital's 

computerized physician order entry 

(CPOE) system. The computer study 

order required that an indication be 

selected for placement, provided 

routine catheter care instructions, and 

had a default stop date of 72 hours 

after placement. A reminder appeared 

after 72 hours asking the ordering 

physician to renew or discontinue the 

catheter order. Physicians had the 

option of using the computer order, a 

written order, or no order. 

Mean duration 

indwelling catheter in 

place (first study 

period): 

Control: 6.63 days 

Intervention: 4.72 days 

p<0.01 

Mean duration 

indwelling catheter in 

place (second study 

period): 

Control group: 8.53 

days 

Intervention group: 

5.56 days 

p<0.01 

Saint 

2005124 United 

States 

Tertiary 

care or 

university 

hospital 

6/2001-

12/ 

2002 

8 

months 

Removal of 

unnecessary 

catheters 

QI Strategies: Clinician reminder 

A printed reminder was attached to the 

physician notes in the charts of patients 

who had a urinary catheter in place for 

>48 hours. The reminder required the 

physician to either order removal of the 

catheter or check a specific reason for 

continuing the catheter (among 6 

reasons that were specified.) Initially, 

the reminders were frequently ignored, 

so plastic tape flags asking physicians 

to "sign here" and alphanumeric 

reminder paging were used to increase 

compliance with the reminder. 

Rate of use of 

indwelling urinary 

catheters 

Control: 

prior to intervention: 

27.8% of patients 

after intervention: 

32.0% of patients 

Intervention: 

before intervention: 

14.4% of patients after 

intervention: 13.3% of 

patients 

p value not reported 
87

Table 11b. Articles addressing prevention of catheter-associated urinary tract infections (studies addressing 

reduction in catheter usage): simple before-after studies of moderate methodologic quality 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

*Greco 

199161 Italy 

Multiple 

hospitals 

of 

different 

types 

12/1988 

– 

6/1989 

19 

months 

Aseptic 

insertion and 

catheter care 

QI Strategies: Clinician education, 

audit and feedback, clinician reminder 

Series of meetings with surgeons and 

nurses from each of participating 

wards. Data on infection incidence and 

practices were discussed and best 

practices reviewed including: 

appropriate use of perioperative 

antibiotics (pre-operative, limited 

duration, appropriate selection), 

avoidance of preoperative shaving, 

closed drainage of urinary catheters 

and surgical drains, implementation of 

respiratory exercises, use of hygienic 

measures for Urinary catheters. 

UTI associated with 

indwelling catheters: 

Infection rate prior to 

intervention: 12.9 per 

100 urinary catheters 

Infection rate after 

intervention: 11.9 per 

100 urinary catheters 

p=NS 

Danchai

vijitr, 

1992118

Thailand 

Multiple 

hospitals 

of 

different 

types 

Not 

specified

Not 

specified

Reduction in 

placement of 

catheters 

QI Strategies: Clinician reminder 

An "indication sheet" was attached to 

charts. This sheet listed indications 

for urethral catheterization and was to 

be filled out by prescribers. It listed 5 

specific indications for catheterization 

(urinary retention, recording hourly 

urine output, injury to urethra, irrigation 

of urinary bladder, and "other"); 

prescribers were to order 

catheterization only for one of the 

specific indications. 

Rate of use of 

indwelling catheters: 

before intervention: 

8.1% of patients 

after intervention: 8.6% 

of patients 

p=NS 

Huang 

2004119 Taiwan 

Tertiary 

care or 

university 

hospital 

1/2002-

12/2002 

1 year Removal of 

unnecessary 

catheters 

QI Strategies: Clinician reminder 

Nursing staff reminded physicians 

daily to remove urinary catheters if 

they were no longer needed five days 

after being inserted. Catheters were 

placed or removed at the discretion of 

the physicians in charge. 

Rate of symptomatic 

urinary tract infection: 

Infection rate prior to 

intervention: 11.5 per 

1,000 catheter-days 

Infection rate after 

intervention: 8.3 per 

1,000 catheter-days 

p<0.01 

Mean duration 

indwelling catheter in 

place: 

before intervention: 7.0 

days 

after intervention: 4.6 

days 

p<0.01 
88

Table 11b. Articles addressing prevention of catheter-associated urinary tract infections (studies addressing reduction in 

catheter usage): simple before-after studies of moderate methodologic quality (continued) 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement intervention Results

Dumigan 

1998121 United 

States 

Community hospital 

with 

residents 

5/1996-

10/1997 

18 

months 

Aseptic 

insertion and 

catheter care 

Removal of 

unnecessary 

catheters 

QI strategies: Clinician education, 

organizational change 

Multidisciplinary effort used to reduce 

CAUTI was implemented according to 

plan-do-check-act methodology. 

Multidisciplinary committee (including 

physicians, nurses, and infection 

control practitioners) created protocols 

for physicians, nurses, and the 

laboratory regarding urinary catheter 

use and procedures. Physicians were 

targeted by creating a list of 

indications for catheter use. Nurses 

received a video presentation on 

insertion technique and standardized 

protocols for catheter care. 

Indications for removing catheters 

were developed, and nurses were 

allowed to remove catheters without a 

physician's order if they were present. 

After protocols were developed, an 

extensive educational campaign was 

used to disseminate them to nurses, 

housestaff, and attending physicians. 

Note: an audit/feedback intervention 

(feedback of CAUTI infection rates) 

was in place prior to the intervention. 

Rate of symptomatic 

urinary tract infection: 

Infection rate prior to 

intervention (CAUTI per 

1,000 catheter-days): 

SICU: 10.3, MICU, 

15.8, CICU, 15.1 

Infection rate after 

intervention: SICU: 8.6; 

MICU: 11.2; CICU: 8.3. 

p value 0.03 for CICU 

only; NS for others 

Topal 

2005122 United 

States 

Tertiary 

care or 

university 

hospital 

Fall 

2002-

Spring 

2003 

18 

months 

Reduction in 

placement of 

catheters / 

Removal of 

unnecessary 

catheters 

QI strategies: Clinician education, 

clinician reminder, organizational 

change 

Three interventions were implemented 

to reduce urinary catheter use and 

CAUTI. Physicians were prompted 

(using the computerized physician 

order entry system) to discontinue 

catheters, maintain catheters for 48 

hours, or maintain catheters 

chronically each time a catheter was 

placed in the ED. Physician and 

nursing staff were educated on lowerrisk alternatives to indwelling devices. 

A nurse-driven protocol was 

introduced to allow nurses to 

discontinue catheters independent of a 

physician's order when patients no 

longer met criteria for catheter use. 

Bladder scanners were purchased to 

allow nurses to assess for urinary 

retention. 

Rate of symptomatic 

urinary tract infection: 

Infection rate prior to 

intervention: 36 per 

1,000 catheter-days 

Infection rate after 

intervention: 11 per 

1,000 catheter-days 

p<0.01 

* This study addresses prevention of surgical site infections and catheter-associated urinary tract infections
89

Studies Addressing Catheter Care 

Two studies conducted educational interventions on catheter care with implementation of a 

clinical guideline in order to reduce CAUTI (Tables 11c-11e). A controlled before-after trial in 

general ward patients117 introduced an infection control liaison nurse to conduct the intervention 

and found an improvement in adherence to the guideline for catheter care on the study wards 

compared to the control wards. The study did not measure CAUTI rates. The other study120 was 

a simple before-after trial in ICU patients that also used audit and feedback of infection rates. 

The intervention was associated with increased guideline adherence, increased compliance with 

hand hygiene, and a reduced rate of CAUTI. 

Finally, one study discussed previously in the VAP section60 introduced an educational 

intervention targeting hand hygiene in an ICU in Guatemala (Table 11e). No effect on CAUTI 

was found, although adherence to hand hygiene protocols did improve. 

Table 11c. Articles addressing prevention of catheter-associated urinary tract infections (studies addressing 

catheter care): controlled studies 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length of 

follow-up 

Preventive 

Interventions 

Quality improvement intervention Results

Ching 

1990117 Hong Kong 

Tertiary 

care or 

university 

hospital 

Not 

specified

Not 

specified

Aseptic 

catheter care 

QI Strategies: Clinician education 

An infection control liaison nurse was 

selected for each ward in the intervention 

group, with another nurse appointed as 

their assistant. The ICLNs and the 

assistants received a 3-hour interactive 

training session from the infection control 

team on a new guideline for appropriate 

urinary catheter care. The guideline 

recommended proper securing of the 

catheter, preventing the catheter and tube 

from kinking, and emptying the draining 

spigot into a collecting container. The 

ICLNs then presented demonstration 

tutorials and lectures to regular ward 

nurses in the intervention wards. The 

tutorials were in small groups and 

attendance was mandatory; the lecture 

was a 30-minute lecture on the new 

guideline. The control wards received 

only the lectures. 

Adherence to 

a clinical 

guideline for 

preventing 

UTI: 

Control: 

before 

intervention: 

32.2% 

after 

intervention: 

51.8% 

Intervention: 

before 

intervention: 

37.9% 

after 

intervention: 

64.0% 

p value for 

comparison 

<0.01 
90

Table 11d. Articles addressing prevention of catheter-associated urinary tract infections (studies addressing 

catheter care): simple before-after studies of moderate methodologic quality 

Author Setting 

and 

Hospital 

Type 

Study 

period 

Length of 

follow-up 

Preventive 

Interventions 

Quality improvement 

intervention 

Results

Rosenthal 

2004120 Argentina 

Private 

hospital 

1/2001-

9/2002 

22 months Hand hygiene 

Aseptic 

catheter care 

QI Strategies: Clinician 

education, audit and feedback 

An educational intervention with 

performance feedback was 

delivered to ICU staff. The 

education focused on compliance 

with handwashing before 

catheter insertion, and 

positioning the catheter to avoid 

compression of the catheter by 

the patient's leg. It is not clear if 

the intervention targeted nurses, 

physicians, or both. Feedback 

on compliance with these 

practices was provided to ICU 

staff (through posters in the ICU) 

and at infection control meetings. 

Compliance rates and CAUTI 

rates were fed back to the ICU 

administrators. 

Rate of symptomatic 

urinary tract infection: 

Infection rate prior to 

intervention: 21.3 per 

1,000 catheter-days 

Infection rate after 

intervention: 12.39 

per 1,000 catheterdays 

p<0.01 

Adherence to 

protocols for hand 

hygiene: 

before intervention: 

23.1% 

after intervention: 

65.2% 

Compliance with 

aseptic insertion and 

catheter care 

guidelines: 

before intervention: 

83% 

after intervention: 

96% 

p<0.01 for both 

process measures 
91

Table 11e. Articles addressing prevention of catheter-associated urinary tract infections (studies addressing catheter 

care): simple before-after studies of poor methodologic quality 

Author Setting and 

Hospital 

Type 

Study 

period 

Length 

of 

followup 

Preventive 

Interventions 

Quality improvement 

intervention 

Results

*Berg 

199560 Guatemala 

Tertiary 

care or 

university 

hospital 

Not 

specified 

1 year Hand hygiene QI Strategies: Clinician 

education 

A multifaceted intervention was 

used to target nosocomial 

infections in the ICU, with both 

general measures and measures 

targeting VAP and CAUTI. 

Nurses and physicians received 

15 educational sessions on 

aseptic technique, stressing 

proper hand washing. The 

educational sessions used 

lectures and demonstrations, and 

individual clinicians also received 

positive and negative feedback 

and reminder signs at the 

bedside. The VAP intervention 

targeted proper use of sterile 

rinse water and improvement in 

aseptic technique for suctioning. 

Providers received more than 15 

interactive conferences on the 

detection, management, and 

prevention of nosocomial 

pneumonia; these included 

lectures, demonstrations, 

individual instruction and 

feedback, and contests. The 

CAUTI intervention consisted of 

changing open urinary drainage 

systems to closed systems 

(aseptic catheter care), with an 

educational session on the new 

catheter. The intervention did not 

specifically target CLABSI, but 

those outcomes are reported. 

Rate of symptomatic 

urinary tract infection: 

before intervention: 

18 per 1,000 

catheter-days 

after intervention: 13 

per 1,000 catheterdays 

p=NS 

Adherence to 

protocols for hand 

hygiene: 

Before intervention: 

5% 

After intervention: 

63% 

p<0.01 

*This study addresses prevention of surgical site infections, central line-associated bloodstream infections, ventilator-associated 

pneumonia and catheter-associated urinary tract infections. 
92

Table 12. Quality criteria for simple before-after studies addressing catheter-associated urinary 

tract infections 

Internal Validity External Validity 

Author Did the study 

report data on 

more than one time 

point before and 

after the 

intervention? 

If the study 

reported infection 

rates, did it also 

report process 

measurements? 

Was the 

intervention 

performed 

independent of 

other QI efforts or 

other changes? 

Did the study 

use NNIS/CDC 

methods for 

measuring 

infections? 

Did the study 

report infection 

rates in 

terms of device 

utilization? 

Berg 199560 ○ ● ▲ ● ●

Danchaivijitr, 

1992118 ○ N/A ▲ N/A N/A 

Greco 199161 ● ○ ○ ○ ●

Huang 

2004119 ○ ● ●

●

●

Rosenthal 

2004120 ○ ● ●

●

●

Topal 

2005122 ○ ○ ▲ ● ●

Dumigan 

1998121 ● ○ ▲ ● ●

●: Yes ○: No ▲: Unclear
93

Chapter 4. Discussion 

Although many studies have been published documenting the effect of quality improvement 

initiatives on prevention of healthcare-associated infections, the published literature is of poor 

methodologic quality overall and does not consistently demonstrate the effectiveness of any 

specific strategy to either reduce infection rates or improve adherence to recommended 

preventive interventions. The available evidence does identify several promising strategies that 

merit more rigorous evaluation and may be appropriate for wider implementation. In the 

following sections, we will summarize our findings for prevention strategies for each target HAI, 

based on the few controlled studies and simple before-after studies with moderate to good 

methodologic quality. 

Surgical Site Infection 

Limited data (consisting of two interrupted time series67, 86 and one before-after study19) 

indicate that educational interventions coupled with audit and feedback may be effective at 

improving adherence to recommended strategies for SSI prevention, specifically appropriate 

antibiotic prophylaxis. Importantly, these strategies resulted in significant improvements in 

appropriate antibiotic timing, which has been documented to be deficient in U.S. hospitals. 

Clinician reminders may also improve perioperative antibiotic prophylaxis (one RCT, one CBA, 

one SBA), especially when incorporated into a computerized physician order entry system. No 

conclusion can be reached regarding the effectiveness of educational interventions alone on 

improving antibiotic prophylaxis practices. We also could not determine the effectiveness of QI 

strategies at promoting perioperative glucose control, perioperative normothermia, or decreasing 

operative site shaving, as very few studies reported data on these process measures. 

We were also unable to determine any strategies effective at reducing SSI rates. Overall, SSI 

rates were statistically significantly reduced in five of 18 studies reporting this measure. In 

studies that did not have important methodologic flaws, surgical site infection rates were not 

consistently reduced, even when process measurements were improved. One study using an 

explicit “bundle” of interventions did improve process measures19 but not infection rates. Audit 

and feedback of SSI rates has been widely advocated, but the effect on surgical site infection 

rates is not clear. This strategy was evaluated in three multicenter studies (two ITS, one CBA66), 

with inconsistent results. 

Central Line-Associated Bloodstream Infections 

Two controlled studies,94, 99 one interrupted time series,96 and four simple before-after 

studies88, 89, 92, 93 of relatively good methodological quality used active educational interventions 

to significantly reduce the incidence of CLABSI. These interventions used demonstrations and 

self-study tutorials to improve adherence to preventive practices during catheter insertion. These 

educational interventions have been evaluated in teaching and non-teaching hospitals, and in 

U.S. and European institutions, increasing their generalizability. Two studies94, 96 used an 

explicit checklist to be filled out during line insertion, with nurses empowered to stop the 

procedure if all preventive interventions were not used, and documented marked reductions in 

CLABSI rates. This strategy may be worthy of wider implementation given its apparent success 
94

in a large population of ICUs in one study.96 We were unable to determine which QI strategies 

are effective at improving specific preventive interventions, as the studies documenting reduced 

CLABSI rates did not consistently report process measures. 

Ventilator-Associated Pneumonia 

Active educational interventions with use of a self-study module for ICU staff appear to be a 

promising strategy for reducing VAP rates, based on two SBA studies.107, 110 These studies used 

explicit clinical guidelines for preventing VAP, incorporating promotion of semirecumbent 

patient positioning and hand hygiene along with oral care, handling of ventilator condensate, and 

other interventions. No conclusion can be reached on the effectiveness of audit and feedback or 

other QI strategies on VAP rates. One SBA study effectively improved adherence to 

semirecumbent patient positioning using an educational- and reminder-based intervention.114

Catheter-Associated Urinary Tract Infection 

Reminders to clinicians appear to be effective at reducing unnecessary catheter usage, 

primarily by reducing the duration of catheterization (two CBA studies123, 124 and two SBA 

studies119, 122). A key element of these studies was the use of an “automatic stop order” 

mandating discontinuation of the catheter after a specific time period (48 to 72 hours) unless the 

physician countermands the order. Three SBA studies using automatic stop orders were also 

associated with reduced CAUTI rates.119, 121, 122 Two of these studies121, 122 allowed nurses to 

remove catheters without a physician order if prespecified indications were met, an intervention 

worthy of future study. We could not determine the effect of other QI strategies on either 

infection rate or process measures. The safety of these interventions—i.e., the need for urethral 

re-catheterization—has not been adequately assessed; however, although re-catheterization is 

undoubtedly uncomfortable and inconvenient for patients, it is unlikely to lead to lasting harm. 

There is insufficient evidence supporting the utility of guidelines for catheter care. 

Limitations 

The quality of included studies was poor. Across all four target HAIs, 52 of 64 included 

studies used a quasi-experimental, before-after design. Even within the limitations of this study 

design, most studies had poor internal validity, chiefly due to reporting data at only one time 

point before and after the intervention (33 of 52 studies). Whether the study reported infection 

rates or process measures (or both), it is very difficult to attribute an improvement in outcomes to 

the intervention on the basis of two data points. The baseline level of HAI rates were generally 

relatively high in most studies, and were above the pooled NNIS median for CLABSI, VAP, and 

UTI. While the NNIS data is not recommended for direct inter-hospital comparisons, the 

relatively high baseline rates raise the concern that the observed improvement (especially in 

before-after studies) could be due to regression to the mean, or even that institutions were 

motivated to study interventions to decrease HAI because of their unusually high infection rates. 

This may simply reflect the fact that many included studies were likely performed as 

documentation of ongoing quality improvement efforts, and not with a specific research agenda. 

Reporting of more time points of baseline data would provide assurance that an acute outbreak 
95

had not temporarily elevated baseline infection rates, and reporting of more data points after the 

intervention would provide greater assurance about the true intervention effect and its 

sustainability. Studies generally used NNIS definitions and used appropriate adjustment for 

device utilization, but given the problems with internal validity, the vast majority of studies 

cannot be considered generalizable. 

We identified only one randomized controlled trial, eight controlled before-after trials, and 

three interrupted time series. These studies also exhibited problems with methodologic quality, 

especially among the CBA studies, in which the majority did not document the rationale for the 

selection of the control group. None of the controlled trials documented blinding of the 

outcomes assessors. 

Reporting of infection rates without reporting accompanying process measures was common 

in our included studies. Of the 47 before-after studies reporting infection rates, only 24 reported 

data on the process measures targeted by the intervention. Accomplishing full adherence to 

recommended care can be difficult even in a clinical trial setting; a recent randomized trial of 

semirecumbent patient positioning found that the target elevation of the head of the bed (45 

degrees) was not achieved in 85 percent of patients randomized to semirecumbent positioning,125

even with the presence of a dedicated research nurse assisting with intervention implementation. 

Given the inherent difficulties present in measuring HAI rates, and the lack of validated methods 

for inter-hospital comparisons of HAI rates, it is very important for process measures to be 

documented and reported. However, many of our included studies implemented an intervention 

with the intention of improving process measures, found a reduction in infection rates, and 

reported that the intervention must have been effective at improving the process, without actually 

documenting so. This is a particular concern in studies using passive interventions such as 

guideline dissemination and lectures. Past research has demonstrated that passive interventions 

are unlikely to achieve significant improvements in provider behavior,126 and thus it is unlikely 

that significant improvement in infection rates should occur as a result of such interventions if 

the appropriate process measures are not in fact improved. 

Although several studies used an explicit clinical guideline for preventing HAIs (particularly 

the studies using educational interventions with self-study tutorials to target CLABSI and VAP), 

only two studies19, 113 directly assessed implementation of the “bundles” recommended by the 

IHI. The organization makes the point that setting the target of complete adherence to a bundle 

of processes “sets the bar high” and motivates overall system redesign rather than targeted 

single-process interventions,44 but there are no data to support this theoretically attractive claim. 

The IHI also recommends specific QI strategies for implementing the “bundles”, such as audit 

and feedback of infection rates and all-or-none measurements, and use of multidisciplinary 

rounds and setting daily patient goals for ICU patients.7

 The very limited published data does 

not allow evaluation of the effectiveness of these strategies. The recommendations of the 

“100,000 Lives” campaign are being widely implemented in U.S. hospitals, providing an 

excellent opportunity for conducting higher-quality studies to determine effective 

implementation strategies. 

In this review, the vast majority (30 of 39) of the studies reporting adherence to process 

measures reported a statistically significant improvement in adherence. This striking lack of 

reporting of negative results is highly likely to be a manifestation of publication bias. Although 

this trend was not as evident among studies reporting infection rates, 21 of 33 studies reporting 

CLABSI, VAP, or CAUTI rates found a statistically significant improvement. Thus, even the 
96

limited conclusions we are able to draw from the evidence may not be representative of overall 

experience with these strategies. 

Other methodologic problems in the included studies are similar to those identified in 

previous volumes in this series. While most studies identified a baseline quality gap (generally 

an elevated HAI rate compared to benchmark standards), the majority did not specifically 

identify barriers to implementation of evidence-based practices or tailor their intervention to 

overcome barriers. Most studies provided few details on the intervention, particularly with 

regards to the intensity of the intervention and its reach (the extent to which those targeted by the 

intervention actually received it). Most studies did not state if other QI interventions were 

underway simultaneously. The median length of follow up was approximately one year across 

all studies, which is likely too short to confirm a sustained improvement in either infection rates 

or process measures. 

Because of the limited number of controlled trials, we were unable to perform any 

quantitative analyses such as median effects analysis. We are thus unable to obtain any estimate 

of the magnitude of the effect that hospitals implementing these strategies may hope to achieve. 

Very few studies reported on any potential adverse effects of the intervention, and no highquality studies assessed the cost-benefit of the intervention. 

Conclusions 

Due to the extensive limitations in the primary data outlined above, we are not able to make 

any firm recommendations for organizations seeking to implement quality improvement 

interventions to reduce healthcare-associated infections. Quality improvement efforts in 

infection control are active, and thus we make the following recommendations for further study 

in this area. 

1. Preliminary data indicates that several strategies are worthy of future study. 

Based on limited evidence, the following quality improvement strategies to reduce 

healthcare-associated infections could be considered for wider implementation, if higher-quality 

studies confirm their effectiveness: 

• Printed or computer-based reminders with use of automatic stop orders to reduce 

unnecessary urethral catheterization. This is the only strategy we identified that is 

supported by more than one controlled study. 

• Printed or computer-based reminders for improving adherence to recommendations for 

timing and duration of surgical antibiotic prophylaxis; 

• Staff education using interactive tutorials (including video and web-based) and 

checklists, to improve adherence to insertion practices for placement of central venous 

catheters; 

• Staff education, including use of interactive tutorials, to improve adherence to preventive 

interventions to prevent ventilator-associated pneumonia. 
97

2. Higher quality studies of QI strategies to implement preventive interventions are 

urgently needed. 

Given the prevalence of HAIs and the associated morbidity and mortality, there is a great 

need for information on how to improve adherence to preventive interventions. We recognize 

that conducting controlled trials may not be practical for many investigators for cost and 

feasibility reasons; as well, it may be unethical to randomize subjects to receive or not receive 

preventive interventions. If performing a controlled trial is impractical, investigators should 

perform interrupted time series analyses to demonstrate that a QI intervention is truly effective. 

At least three time points of data should be reported before and after a clearly defined 

intervention time period, and a formal ITS statistical analysis should be conducted. Studies 

should ideally report the effect of the intervention on both process measures (adherence to 

recommended preventive interventions) and infection rates. Studies should also document if 

other QI efforts were underway simultaneously, and use standardized definitions for measuring 

and reporting HAIs. Formal evaluation of the cost-benefit of the intervention should be 

conducted, and adverse events should be documented. 

We acknowledge that even conducting higher-quality nonrandomized trials may pose 

logistical challenges. Monitoring infection rates over a sustained period of time requires 

adequate infection control resources, which may not currently be in place at many U.S. 

hospitals.127, 128 In an era of public reporting of infection rates, hospitals may feel pressured to 

respond quickly to increases in measured infection rates, even if these rates may not be directly 

tied to poor adherence to preventive practices. Measuring adherence to preventive interventions 

is resource intensive,129 and requires additional trained personnel. If public reporting of infection 

rates becomes more widespread, as seems likely, investment in infection control resources will 

be necessary in order to adequately monitor infection rates and process measures and continue 

study of implementation of effective preventive measures. 

We also believe that there are potential cross-cutting opportunities, in which interventions 

proven to work for one target should be considered for others. For example, empowering nurses 

to remove urinary catheters when patients met prespecified criteria, when coupled with earlier 

studies that demonstrated the value of respiratory-therapist-driven ventilator weaning 

algorithms,130 may point the way to more interventions managed by nonphysician providers, 

working under carefully crafted protocols. Another example is empowering nurses to stop 

central venous catheter insertion if a checklist of preventive interventions is not followed; 

empowering nonphysician providers in this fashion could be applied to preventive interventions 

for many HAIs. 

We emphasize that the level of evidence supporting these strategies is below that supporting 

the recommendations made in prior volumes of this series.47, 48 Thus, we are unable to 

recommend strongly that these QI strategies be more widely implemented, as--in addition to the 

poor quality of supporting evidence--the potential adverse consequences and cost-benefit of 

these strategies has not been assessed. Wider implementation of these measures (most of which 

do not appear to be complex or costly) should be feasible, but should only be performed if a 

formal plan for evaluating their effectiveness is in place. 

The lack of strong evidence supporting use of specific QI strategies should not be taken to 

mean that ongoing QI efforts in HAI prevention have been uniformly unsuccessful, or that 

current strategies should not be continued. Population-level data from Europe shows that HAI 

incidence can be reduced through use of infection control surveillance,131 and some institutions 
98

have documented sustained reductions in specific HAI.105, 106 The mechanisms behind these 

successes and the best means of translating them into other settings remain to be determined. 

High-quality evidence exists to support many preventive interventions that are very effective at 

reducing HAI incidence. Given the huge toll in human lives, antibiotic use (leading to more 

resistant infections) and costs caused by hospital-acquired infections, efforts to better understand 

how to implement these interventions should be prioritized. 
99

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List of Acronyms/Abbreviations 

Acronym/Abbreviation Meaning 

ARIMA Autoregressive integrated moving-average 

CAUTI Catheter-associated urinary tract infection 

CABG Coronary artery bypass graft 

CDC Centers for Disease Control and Prevention 

CLABSI Catheter line-associated blood stream infection 

CPOE Computerized physician order entry 

CVC Central venous catheter 

DVT Deep vein thrombosis 

EPOC Cochrane Effective Practice and Organisation of Care 

ICU Intensive care unit 

IHI Institute for 

ITS Interrupted time series 

HAI Healthcare-associated infection 

HICPAC Healthcare Infection Control Practices Advisory Committee 

JCAHO Joint Commission for Accreditation of Healthcare Organizations 

LCBI Laboratory Confirmed Bloodstream Infection 

MICU Medical intensive care unit 

NNIS National Nosocomial Infection Surveillance System 

NSIPP National Surgical Infection Prevention Project 

QI Quality improvement 

RCP Respiratory care practitioners 

SBT Simple before-after 

SCIP Surgical Care Improvement Project 

SENIC Study of the Effectiveness of Nosocomial Infection Control 

SICU Surgical intensive care unit 

SSI Surgical site infection 

VAP Ventilator-associated pnemonia 
APPENDIXES: 

to 

“Closing the Quality Gap: A Critical Analysis of Quality 

Improvement Strategies, Volume 6—Prevention 

of Healthcare-Associated Infections” 

Prepared by the Stanford University-UCSF 

Evidence-based Practice Center 

(Contract #290-02-0017) 
A1

Appendix A. Literature Search Strategy 

Date: 2/13/06 

#1 

targets QI strategies that tend to be 

multi-factorial using relevant MeSH 

terms and title words 

Patient-Centered Care [mh] or Progressive Patient Care [mh] 

or Critical Pathways [mh] or Delivery of Health Care, 

Integrated [mh] or Patient Care Team [mh] or Behavior 

Control [mh] or ((coordination [tw] or coordinated [tw] or 

Multifactorial [tw] or Multi-factorial [tw] or Multicomponent 

[tw] or Multi-component [tw] or multidisciplinary [tw] or 

multi-disciplinary [tw] or interdisciplinary [tw] or interdisciplinary [tw] or integrated [tw] or community-based [tw] 

or organized [tw] or comprehensive [tw]) and (program*[tw] 

or care [tw] or approach [tw] or intervention [tw] or strategy 

[tw] or strategies [tw] or management [tw] or managing [tw] 

or center*[tw])) or Organization and Administration [mh] or 

bundle*[tw]

813885 

#2 

targets TQM and CQI 

Total Quality Management [mh] OR Quality control [mh] OR 

TQM [tw] OR CQI [tw] OR (quality [tw] AND (continuous 

[tw] OR total [tw]) AND (management [tw] OR improvement 

[tw])) 

41902 

#3 

targets provider education 

Education, Continuing [mh] OR Education, Nursing [mh] OR 

Education, Medical [mh] OR Inservice Training [mh] OR 

Programmed Instruction [mh] OR ((Education [tw]AND 

Continuing [tw]) AND (medical [tw] OR professional* [tw] 

OR nursing [tw] OR physician* [tw] OR nurse* [tw])) OR 

(outreach [tw] AND (visit* [tw] OR educational [tw]) OR 

(academic [tw] AND detailing [tw])) 

170009 

#4 

targets diffusion of innovation 

Diffusion of Innovation [mh] OR (Diffusion [ti] AND 

(Innovation [ti] OR technology [ti])) 

6710 

#5 

targets audit & feedback, reminder 

systems, and financial incentives 

Medical audit [mh] OR ((Audit [tw] OR feedback [tw] OR 

compliance [tw] OR adherence [tw] OR training [tw]) AND 

(improvement* [tw] OR improving [tw] OR improves [tw] 

OR improve [tw] OR guideline* [tw] OR practice* [tw] OR 

medical [tw] OR provider* [tw] OR physician* [tw] OR 

nurse* [tw] OR clinician* [tw] OR academic [tw] OR visit* 

[tw])) OR Reminder Systems [mh] OR Reminder* [tw] OR 

((financial [tw] OR economic [tw] OR physician* [tw] OR 

patient*) AND incentive* [tw]) OR Reimbursement 

Mechanisms [mh] or Guideline Adherence [mh] OR practice 

guidelines [mh] 

184663 

#6 Medical Informatics [mh] OR computer [tw] OR (decision 

[tw] AND (support [tw] or analysis [tw)) 

345989 

#7 

All QI studies 

#1 or #2 or #3 Or #4 or #5 or #6 1326026 

#8 

Surgical site infection terms 

Surgical wound infection[mh] OR surgical site 

infection*[tiab] OR postoperative infection*[ti] OR 

postsurgical infection*[ti] OR wound infection*[ti] OR sternal 

wound infection*[tiab] OR postoperative[ti] OR postsurgical[ti] 

59870 
A2

#9 

Combination of QI terms with SSI 

terms 

#7 AND #8 3438 

#10 

RCT search 

Randomised [ti] OR Randomized [ti] OR Controlled [ti] OR 

intervention [ti] OR evaluation [ti] OR impact [ti] OR 

effectiveness [ti] OR Evaluation [ti] OR Studies [ti] OR study 

[ti] Comparative [ti] OR Feasibility [ti] OR Program [ti] OR 

Design [ti] OR Clinical Trial [pt] OR Randomized Controlled 

Trial [pt] OR Epidemiologic Studies [mh] OR Evaluation 

Studies [mh] OR Comparative Study [mh] OR Feasibility 

Studies [mh] OR Intervention Studies [mh] OR Program 

Evaluation [mh] OR Epidemiologic Research Design [mh]

2702355 

#11 

Meta-analysis, systematic review 

search 

((meta-analysis [pt] OR meta-analysis [tw] OR metanalysis 

[tw]) OR ((review [pt] OR guideline [pt] OR consensus [ti] 

OR guideline* [ti] OR literature [ti] OR overview [ti] OR 

review [ti] OR Decision Support Techniques [mh]) AND 

((Cochrane [tw] OR Medline [tw] OR CINAHL [tw] OR 

(National [tw] AND Library [tw])) OR (handsearch* [tw] OR 

search* [tw] OR searching [tw]) AND (hand [tw] OR manual 

[tw] OR electronic [tw] OR bibliographi* [tw] OR database* 

OR (Cochrane [tw] OR Medline [tw] OR CINAHL [tw] OR 

(National [tw] AND Library [tw]))))) OR ((synthesis [ti] OR 

overview [ti] OR review [ti] OR survey [ti]) AND (systematic 

[ti] OR critical [ti] OR methodologic [ti] OR quantitative [ti] 

OR qualitative [ti] OR literature [ti] OR evidence [ti] OR 

evidence-based [ti]))) BUTNOT (editorial [pt] OR comment 

[pt] OR letter [pt]) 

89605 

#12 

All original research 

#10 OR #11 2766210 

#13 

Combination of QI terms with SSI 

terms, limited to original research 

only 

#9 AND #12 1837 

#14 

#SSI/QI search limited to English 

only 

#13 AND Limits: English 1532 

#15 

CLABSI search 

(restrict to English only) 

(Catheterization, Central Venous [MeSH] OR central line*[ti] 

OR central venous catheter*[ti]) AND (Cross infection [mh] 

 OR bacteremia [mh] OR nosocomial [tiab] OR “healthcare 

associated”[tiab] OR “hospital acquired”[tiab] OR 

bundle[tiab]) 

829 

#16 

VAP search 

(restrict to English only) 

(Respiration, Artificial[mh] OR mechanically ventilated*[ti] 

OR intubated*[ti] OR mechanical ventilation*[ti] or ventilator 

associated*[ti]) AND (Cross infection [mh] OR bacteremia 

[mh] OR nosocomial [tiab] OR “healthcare associated”[tiab] 

OR “hospital acquired”[tiab] OR bundle[tiab] ) 

1034 

#17 

UCUTI search 

(restrict to English only) 

(Urinary catheterization[mh] OR urinary catheter*[tiab]) AND 

(Cross infection [mh] OR bacteremia [mh] OR nosocomial 

[tiab] OR “hospital-acquired”[tiab] OR “healthcareassociated”[tiab] OR bundle[tiab])

602 
A3

Supplemental searches 

#S1 

Nosocomial infection systematic 

reviews (limited to English only) 

Cross infection[mh] AND systematic[sb] 401 

#S2 

Handwashing systematic reviews 

(limited to English only) 

Handwashing[mh] AND systematic[sb] 60 

#S3 

Author searches 

Pronovost p[au] OR Gastmeier P[au] OR Gyssens IC[au] 220 

TOTAL CITATIONS 

(#14 +#16 +#18 + #20 +#S1 +#S2) 

#14 OR #15 OR #16 OR #17 OR #S1 OR #S2 OR #S3 

4678 
B1

Appendix B. Sample Data Abstraction Forms 

Stage 1 (Screening Title and Abstract) Form 

1. Does this article report or evaluate the results of an intervention (whether performed by the 

investigators or not)? 

o Yes 

o No 

o Can't tell 

 

2. Does the article involve quality improvement or a QI strategy? 

o Yes - involves quality improvement or a QI strategy 

o Yes - systematic review of evaluations of a QI strategy 

o No 

o Can't tell 

3. Should this article proceed to article abstraction stage for this topic? 

o Yes - evaluates a QI strategy involving nosocomial infections 

o No – ineligible topic* (focused on community-acquired infections, outpatient care, or 

specific nosocomial infection other than CLABSI, VAP, SSI, or UCUTI) 

o No - not an evaluation or not QI 

o Can't tell - need article 

o No - but useful background article 

o No - foreign language article 

 

4. What type of study design was used? 

o RCT or quasi-RCT 

o CBA** or ITS *** 

o Simple before-after study or time series not meeting ITS definition 

o Observational (e.g., cohort study, cross-section, case-control) 

o Systematic review or meta-analysis 

o Economic or decision analysis, modeling 

o Non-research (commentary, review, news) 

o Qualitative research (e.g., focus groups) 

o Guideline or consensus statement 

o Can't tell (need article) 

 

* Note that at this stage, err in favor of including articles unless they clearly address infections 

other than those listed below. Also, if an article addresses general nosocomial infection 

prevention, err in favor of including it at this stage. 

CLABSI = central line associated blood stream infection (synonyms: central venous catheter 

associated infection, central venous catheter sepsis, central line sepsis) 

VAP = ventilator associated pneumonia 

SSI = surgical site infection (synonyms: surgical wound infection, postoperative infection) 
B2

UCUTI = urinary catheter associated urinary tract infection (synonyms: foley catheter 

associated urinary tract infection, urinary catheter related infection, urinary catheter associated 

cystitis) 

** Controlled Before After (CBA) requires contemporaneous observation periods for control 

and intervention groups AND judgment that control represents a comparable group or setting 

 

*** Interrupted time series (ITS) requires statement of well-defined time period for intervention 

implementation AND at least three time points both before and after 

 

Note: At this stage of triage, if there is a reasonable chance article is a clinical trial, CBA or 

ITS, err on the side of inclusion at that level. Stricter criteria can be applied more reliably at 

next stage of abstraction using full text of article. Similarly, if there is a reasonable chance 

article is a systematic review, designate it as such so article can be pulled. 

 5. What category of study question is addressed by the article? 

o Can the incidence of CBSI be reduced? 

o Can the incidence of SSI be reduced? 

o Can the incidence of VAP be reduced? 

o Can the incidence of UCUTI be reduced? 

o Can nosocomial infections in hospitals be reduced? 

o Not applicable – excluded above [answer only if excluded at Q1 or Q2 above] 

o Can't tell (need article) 

Stage 2 (Full Text) Abstraction Form 

1. Does this article merit full text abstraction? 

o Yes 

o No – not QI or not an evaluation of a QI strategy* [exclusion] 

o No – ineligible study design (i.e., not RCT, CBA, or ITS) [exclusion] 

o No - excluded topic (Focus on evaluation of infections which are not hospital acquired or not 

CLABSI, SSI, VAP, or UTI) [exclusion]

o No – no eligible outcomes** [exclusion] 

o No- other [exclusion] 

*Treatment evaluation studies (studies of the effect of a specific preventive intervention or therapy on 

nosocomial infection rates) should not be included. To be included, studies should explicitly attempt to 

promote use of a particular intervention, rather than evaluating the effect of the intervention itself. 

**Eligible outcomes include physician or staff adherence to recommended practices, or improvement in 

rate of SSI, CLABSI, VAP, or UTI. Article must report at least one of these two outcomes to be eligible for 

full text abstraction. Studies that addressed general nosocomial infection prevention should be 

abstracted ONLY if they report outcomes pertaining to SSI, CLABSI, VAP or UTI. 

2. Does this article present data overlapping with another article? 

o Exclude this article as a duplicate publication (identify included citation being duplicated) 

[exclusion] 
B3

o Include this article, but obtain listed citation to help with abstraction (e.g., separate methods 

paper; identify required citation) 

o No or N/A 

3. Does abstraction of this study require information from methods or results reported in other citations? 

o Yes (specify) 

o No 

4. Does the article report data for more than one comparison (i.e., should it be abstracted as more than 

one study)? 

o Yes (specify which comparison is being abstracted here and which others will be abstracted 

elsewhere) 

o No 

5. What category of study question is addressed by the article? [check all that apply] 

o Surgical Site Infections 

o Central Line Infections 

o Ventilator Acquired Pneumonia 

o Urinary Catheter-related UTI 

o Other [describe; discuss with Sumant before proceeding] 

6. For studies addressing Surgical Site Infections: which of the following specific preventive interventions 

were targeted? 

o Hand hygiene 

o appropriate use of perioperative antibiotics 

o decreasing use of preoperative shaving of the operative site 

o improving perioperative glucose control 

o perioperative normothermia 

o audit and feedback of infection rates to hospitals or individual clinicians 

o None of the above (discuss with Sumant before proceeding) 

o N/A – article does not address surgical site infections 

7. For studies addressing central line-associated bloodstream infections: which of the following specific 

preventive interventions were targeted? 

o hand hygiene 

o maximal sterile barrier precautions 

o appropriate insertion site selection 

o chlorhexidine skin disinfection 

o prompt removal of unnecessary catheters 

o None of the above (discuss with Sumant before proceeding) 

o N/A – article does not address central line-associated bloodstream infections 

8. For studies addressing ventilator-associated pneumonia: which of the following specific preventive 

interventions were targeted? 

o hand hygiene 

o head of bed elevation above 30 degrees 

o daily interruption of sedation 

o None of the above (discuss with Sumant before proceeding) 

o N/A – article does not address ventilator-associated pneumonia 

9. For studies addressing urinary catheter-associated urinary tract infections: which of the following 

specific preventive interventions were targeted? 

o hand hygiene 

o elevation of the head of the bed 

o aseptic insertion and catheter care 
B4

o None of the above (discuss with Sumant before proceeding) 

o N/A – article does not address urinary catheter-associated urinary tract infections 

10. Describe the QI strategy used and its salient features. [text box] 

A) Study Setting and Participants 

11. In what country did the study take place? 

o US 

o Non-US [specify] 

12. When did the study take place? 

o If supplied, give exact dates of study period (beginning to end of intervention period) 

o Not reported 

13. In what type of hospital did the study take place? 

o Tertiary care or university hospital 

o Community hospital with residents 

o Non-teaching community hospital 

o More than one hospital of different types (specify) 

o Other or unclear (specify) 

14. Who was targeted by the intervention? (check all that apply) 

o All clinical staff 

o Physicians 

o Nurses 

o Respiratory therapists 

o Other ancillary staff [specify] 

o Patients 

o Other [specify] 

15. In what clinical setting did the study take place? (check all that apply) 

o Intensive care unit (specify if medical, surgical, pediatric or other) 

o Operating room 

o General inpatient ward (non-ICU) 

o Other [specify] 

16. Were patients in the study selected on the basis of specific clinical characteristics? (check all that 

apply) 

o Postoperative patients (specify type of surgery, if supplied) 

o Patients with specific disease process (specify) 

o Intubated (mechanically ventilated) patients 

o Other (specify) 

o No specific clinical characteristics 

17. Were patients in the study selected on the basis of specific demographic characteristics? (check all 

that apply) 

o Children (specify age groups) 

o Elderly (specify age groups) 

o Specific type of insurance (i.e., patients within a particular HMO) (describe) 

o Other demographic characteristic (describe) 

o No specific demographic targeted 
B5

18. What type of intervention was provided to the control population? 

o No intervention or usual care 

o Some form of low intensity intervention (describe) 

o No true control - just two or more different types of intervention (discuss with other reviewers; 

study may need to be excluded) 

B) Study Design 

19. What was the study design? 

o Randomized trial (state method of randomization if described) 

o Quasi-randomized trial (state basis for treatment allocation, e.g.,alternating patients, calendar 

date, even or odd identification numbers) 

o Controlled before-after study* 

o Interrupted time series** 

o Simple before-after*** 

*Controlled Before After (CBA) requires contemporaneous observation periods for control and 

intervention groups AND judgment that control represents a comparable group or setting 

** Interrupted time series (ITS) requires statement of well-defined time period for intervention 

implementation AND measurement of data at three or more time points both before and after intervention. 

*** Simple before-after (SBA) requires defined observation period for control and intervention periods. 

20. What was the unit of randomization or treatment allocation? 

o Patient 

o Provider 

o Hospital ward or unit 

o Entire hospital 

o Firm (describe) 

o Institution 

o Other 

o Not applicable—ITS or simple before-after study (skip to question 24) 

21. For the unit of treatment allocation above, state sample size in each group: 

o control group 

o intervention group 

o Not stated or not clear (explain) 

*If sample size differs for outcomes, detail differences in "Not stated or not clear" text box. For simple 

before-after studies, enter pre-intervention sample size in “control group” box and post-intervention 

sample size in “intervention group” box 

22. If unit of analysis differed from unit of treatment allocation (e.g., providers randomized, but patient 

outcomes analyzed), state sample size in each group: 

o control group 

o intervention group 

o Not stated or not clear 

o Not applicable (unit of analysis same as unit of treatment allocation above) 
B6

23. If unit of analysis differed from unit of treatment allocation, did authors acknowledge this issue and/or 

make appropriate adjustments? 

o Yes (describe) 

o No 

o Not applicable (unit of analysis did not differ from unit of treatment allocation) 

24. Were the patients and providers in the control site (or pre-intervention period for SBA or ITS studies) 

comparable to the intervention site? 

o Yes (skip to question 26) 

o No (explain why not) 

o Unclear (describe)

25. If “no”, were efforts made to adjust outcomes for underlying baseline differences in patient and 

provider characteristics? 

o Yes 

o No (explain why not) 

o Unclear (describe) 

Design criteria for randomized and quasi-randomized trials 

(If study is a CBA, skip to question 31; if SBA, skip to question 33; if ITS, skip to question 35) 

26. Did the study have a cross over design? (Patients randomized to a sequence of interventions such as 

treatment A followed by treatment B in one group and treatment B followed by treatment A in the other 

group). 

o Yes (describe) 

o No 

o Not sure - clarify with other reviewers before proceeding 

27. Was there adequate concealment of treatment allocation? 

o Yes (unit of allocation was institution, team or professional and randomization process explicity 

described,OR unit of allocation was patient or episode of care and some form of centralized 

randomization scheme or sealed envelopes used) 

o Not clear (only partially meets above criteria) or not stated - specify which 

o No - inadequate concealment (enrollment of patients in alternation or through use of even/odd 

identifying numbers OR unit of allocation was patient or episode of care and reported use of any 

allocation process that is entirely transparent before assignment (e.g., open list of random 

numbers) OR allocation was altered byinvestigators, professionals or patients) 

28. Were patients blind to intervention/treatment allocation? 

o Yes 

o No 

o Not sure (explain) 

o Not applicable (patients not actively involved in study - e.g., provider-focused intervention with 

patient level data obtained retrospectively from charts) 

29. Were providers blind to intervention/treatment allocation? 

o Yes 

o No 

o Not sure (explain) 

o Not applicable (explain) 
B7

30. Were outcomes assessors blinded to intervention/treatment allocation? 

o Yes 

o No 

o Not sure (explain) 

o Not applicable (explain) 

Design criteria for CBA trials 

31. Were measurements in the control group performed at the same time as the intervention group? 

o Yes 

o No 

o Unclear 

32. Were the criteria used for selecting the control site explained? 

o Yes (describe) 

o No 

Design criteria for SBA trials 

33. Was the data for the “before” period collected during the same time of the year as the “after” period 

(e.g., data collected from June-November, but during different years)? 

o Yes 

o No (describe) 

34. If the data was collected at different times of the year, were efforts made to correct for this? 

o Yes (describe) 

o No 

Design criteria for ITS trials 

35. Was the data analyzed using a formal test for trend (time series ANOVA or regression)? 

• Yes 

• No 

• Unclear 

36. (For all studies) Do any methodologic aspects of the study design not captured above seriously 

undermine 

appropriateness of inclusion? 

• Yes (explain) 

• No (use text box to document any non-fatal, but still noteworthy methodological features) 

C) Quality Improvement Attributes of Intervention 

37. Was the intervention performed independent of other quality improvement efforts or other changes? 

• Yes 

• No (specify other interventions that took place) 

• Unclear 

38. Did the investigators identify a specific quality gap (a difference between optimal and actual care) in 

the study population? 

• Yes (describe) 

• No 
B8

39. Did the QI strategy involve PATIENT EDUCATION? 

o Yes 

o No patient education (skip to question 43) 

40. Which of the following educational strategies was used? (check all that apply) 

o One-on-one session, in person or via telephone 

o Group session (e.g., classes) 

o Distribution of printed or audiovisual materials (e.g., pamphlets or poster in waiting room) 

o Interactive computer-based learning 

o Provision of clinical data to patient (e.g., test results) 

o Not sure or other (describe) 

41. In what setting was the educational content delivered? (check all that apply) 

o Clinical setting (e.g., office or emergency department) 

o Other or unclear (describe) 

42. Who was responsible for delivery of the educational content? (check all that apply) 

o Physician 

o Nurse or nurse practitioner 

o Other ancillary health provider (describe) 

o No specific delivery person (e.g., entirely mailed, computer-based, or passively distributed 

content) 

43. Did the intervention involve PROVIDER EDUCATION? 

o Yes 

o No (skip to question 49) 

44. Who was the target of the educational intervention? (check all that apply) 

o Attending (staff) physicians 

o Residents or fellows 

o Medical students 

o Nurse practitioners 

o Nurses 

o Respiratory therapists 

o Other (specify) 

45. Which of the following educational strategies was used? (check all that apply) 

o Distribution of educational materials (published or printed recommendations for clinical care, 

including clinical practice guidelines, audio-visual materials and electronic publications) 

o Meetings or lectures (e.g., traditional CME) 

o Educational outreach visits (e.g., “academic detailing”—a trained person who met with providers 

in their practice settings to give information with the intent of changing the provider's practice) 

o Interactive in-person education (e.g., workshops or procedure demonstrations) 

o Computer- or internet-based interactive tutorials (e.g., self-study modules) 

o Consensus-building sessions (e.g.,for development of guideline) 

o Not sure or other (describe) 

46. Were all components of the educational intervention delivered to all targets of the intervention? 

o Yes 

o No (specify which targets received which components of the intervention) 

o Unclear or not specified 

47. In what setting was the educational content delivered? (check all that apply) 

o Regularly scheduled staff meeting (specify) 

o Specially scheduled on-site educational meeting (i.e., in-service class) 

o Off-site meeting (e.g., CME) 
B9

o Independent study (e.g., computer- or paper-based tutorial) 

o Other (describe) 

o Not clear or not specified 

48. Who was responsible for delivery of the educational content? (check all that apply) 

o Physician expert opinion leader (describe how selected) 

o Other physician (including colleagues) 

o Infection control practitioner 

o Nurse 

o Pharmacist 

o Other (describe) 

o Not clear or not specified 

o No specific delivery person (entirely independent study or passively delivered content) 

49. Did the QI strategy involve a PROVIDER REMINDER system*? 

o Chart based decision support or reminder system* 

o Computer based decision support or reminder system 

o Not sure 

o No or N/A 

* Patient or provider encounter specific information, provided verbally, on paper or on a computer screen, 

which is intended to prompt provider to recall information at the time of the patient encounter (e.g., 

reminder to remove catheter) 

50. Did the QI strategy involve provider AUDIT AND FEEDBACK*? (check all that apply) 

o feedback of infections (or infection rates) to individual provider 

o feedback of infections/infection rates to practice or hospital 

o feedback of rate of adherence to preventive interventions to individual provider 

o feedback of rate of adherence to preventive interventions to practice or hospital 

o Public reporting of performance data (state if individual data or data for a group or institution) 

o Benchmarking** 

o Not sure or other 

o No or N/A 

*Any summary of clinical performance of health care over a specified period of time, e.g., reporting of 

surgical site infection rates. 

**Benchmarking refers to the provision of performance data from institutions or providers regarded as 

"leaders in the field." These data provide targets for other providers and institutions to emulate. 

51. Did the QI strategy involve ORGANIZATIONAL CHANGE? 

o Changes in team structure (e.g., creation of a dedicated procedure team) (specify) 

o Revision of professional roles among health professionals (e.g., authorizing nurse to stop a 

procedure if proper infection control procedures were not followed) (specify) 

o Increased staffing without changes in roles (e.g., adding more nurses) (specify) 

o TQM/CQI - cycles of measurement of quality problems, design of interventions, implementation 

and remeasurement 

o Changes in medical records systems -- e.g.,changing from paper to computerized records, 

patient tracking systems (specify) 

o Communication and case discussion between distant health professionals (e.g., telemedicine) 

o Not sure or other (describe) 

o No or N/A 
B10

52. Did the intervention involve FINANCIAL OR REGULATORY INCENTIVES DIRECTED AT 

PROVIDERS? 

o Financial incentives for achievement of performance goals (describe) 

o Regulatory mandates (e.g., need for completion of educational module before performing 

procedures) (describe) 

o Other (describe) 

o No component of provider-directed financial or regulatory incentives 

53. Did the intervention involve FINANCIAL OR REGULATORY INCENTIVES DIRECTED AT A 

PRACTICE OR HEALTH SYSTEM? 

o Yes (describe) 

o No component of health-system-directed financial or regulatory incentives 

54. Did the study use an explicit clinical guideline, checklist, or “bundle” of multiple types of 

interventions? 

o Yes 

o No 

55. Use textbox to state any important study features or concerns not captured above. 

D) Results 

56. For unit of treatment allocation (e.g., clinics, providers, patients), were results reported for at least 

80% of participants? 

o Yes (state %) 

o No (state %) 

o Not stated 

o Does not apply – SBA or ITS study 

57. If unit of analysis differed from unit of treatment allocation (e.g., providers randomized, but patient 

level outcomes 

analyzed), were results reported for at least 80% of participants? 

o Yes (state %) 

o No (state %) 

o Not stated or not clear 

o Not applicable (unit of analysis same as unit of treatment allocation, or study is SBA or ITS) 

58. What was the length of the study follow-up period? (describe) 

Studies addressing Surgical Site Infections 

59. Did the study address Surgical Site Infections? 

o Yes 

o No (go to question 85) 

60. Which specific surgeries were targeted by the intervention? (select all that apply) 

o Cardiothoracic surgery (includes coronary artery bypass graft) (specify) 

o Vascular surgery (specify) 

o Orthopedic surgery (includes total knee replacement, total hip replacement) (specify) 

o Gynecologic surgery (includes hysterectomy) (specify) 

o Colorectal surgery (specify) 

o Other type of surgery not listed above (specify) 

o All surgeries performed at a hospital or hospitals 

o Not clear or not specified 
B11

61. What were the outcome types? (check all that apply) 

o Surgical site infection rate 

o Compliance with Hand hygiene 

o Compliance with appropriate timing of perioperative antibiotics (enter definition of appropriate 

timing as specified in study) 

o Compliance with administering perioperative antibiotics for the appropriate duration (enter 

definition of appropriate duration as defined in the study) 

o Compliance with appropriate selection of perioperative antibiotics (list which antibiotics were 

recommended and nonrecommended) 

o Compliance with decreasing use of preoperative shaving of the operative site 

o Compliance with improving perioperative glucose control 

o Compliance with perioperative normothermia 

o Compliance with a clinical guideline for preventing surgical site infections (use this if study 

mandated an explicit guideline or “bundle” incorporating more than one of the interventions 

described above) 

o Costs associated with intervention 

o Adverse effects of the intervention [specify] 

o Provider satisfaction with QI strategy 

o Not sure or other (describe) 

62. If the study reported surgical site infection rates, did the study define infections according to Centers 

for Disease Control (CDC) or National Nosocomial Infection Surveillance System (NNIS) protocols? 

o Yes 

o No 

o Unclear 

63. Which SSI were measured? (check all that apply) 

o Superficial wound infections 

o Deep incisional or organ space infections 

o All surgical site infections 

o Other (describe) 

o No specific definition provided 

64. If wound infection was used as an outcome, what was the duration of surveillance? 

o If specified, enter length of post-operative surveillance (text box) 

65. For studies reporting data in the form of surgical site infection rate, provide the following data for the 

CONTROL group. If data is missing, record “NR” 

o Exact units of measurement 

o Infection rate prior to intervention (s) 

o Infection rate after intervention(s) (Not applicable to SBA studies) 

o Percentage change in infection rate (Not applicable to SBA studies) 

o Does not apply – simple before-after study 

66. For studies reporting data in the form of surgical site infection rate, provide the following data for the 

INTERVENTION group; if data is missing, record “NR”. Note: for simple before-after studies, enter 

“before” data in “prior to intervention” box and “after” data in “after intervention” box 

o Exact units of measurement 

o Infection rate prior to intervention 

o Infection rate after intervention 

67. Enter any data on surgical site infection rates not abstracted above here: 

o Control group before intervention 

o Control group after intervention 

o Intervention group before intervention 

o Intervention group after intervention 
B12

68. For studies reporting data in the form of adherence to hand hygiene, provide the following data for 

the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

69. For studies reporting data in the form of adherence to hand hygiene, provide the following data for the 

INTERVENTION group; if data is missing, record “NR”. Note: enter all data for simple before-after 

studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 

70. For studies reporting data in the form of adherence to appropriate timing of perioperative antibiotics, 

provide the following data for the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

70. For studies reporting data in the form of adherence to administering perioperative antibiotics for the 

appropriate duration, provide the following data for the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

70. For studies reporting data in the form of adherence to appropriate selection of perioperative 

antibiotics, provide the following data for the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

71. For studies reporting data in the form of adherence to appropriate use of perioperative antibiotics, 

provide the following data for the INTERVENTION group; if data is missing, record “NR”. Note: enter all 

data for simple before-after studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 

72. For studies reporting data in the form of adherence to protocols for perioperative shaving of the 

surgical site, provide the following data for the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 
B13

73. For studies reporting data in the form of adherence to protocols for perioperative shaving of the 

surgical site, provide the following data for the INTERVENTION group; if data is missing, record “NR”. 

Note: enter all data for simple before-after studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 

74. For studies reporting data in the form of adherence to protocols for perioperative normothermia, 

provide the following data for the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

75. For studies reporting data in the form of adherence to protocols for perioperative normothermia, 

provide the following data for the INTERVENTION group; if data is missing, record “NR”. Note: enter all 

data for simple before-after studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 

76. For studies reporting data in the form of adherence to protocols for perioperative glucose control, 

provide the following data for the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

77. For studies reporting data in the form of adherence to protocols for perioperative glucose control, 

provide the following data for the INTERVENTION group; if data is missing, record “NR”. Note: enter all 

data for simple before-after studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 

78. Provide the following data for other types of measurements of adherence to preventive interventions 

not abstracted above: 

o Specific preventive intervention and units of measurement 

o Value in CONTROL group before intervention 

o Value in CONTROL group after intervention 

o Value in INTERVENTION group before intervention 

o Value in INTERVENTION group after intervention 

Measures of costs 

Note: cost outcomes should be abstracted only if the study also has usable data for one of the primary 

outcomes (nosocomial infection rate or provider compliance rate) 
B14

79. For studies reporting cost outcomes, what specific measures were used? 

o Total cost of surgical site infection to hospital or health system 

o Total cost of inappropriate antimicrobial prophylaxis averted 

o Total cost of interventions to prevent surgical site infection 

o Other (describe) 

o No measurement of costs 

80. For studies reporting the total cost of surgical site infections, record the following data: 

(Note: for simple before-after studies, enter all data in “intervention” boxes) 

o Exact units of measurement 

o Total costs in CONTROL group before intervention 

o Total costs in CONTROL group after intervention 

o Cost difference before intervention (intervention – control) 

o Total costs in INTERVENTION group before intervention 

o Total costs in INTERVENTION group after intervention 

o Cost difference after intervention (intervention – control) 

o Net change in costs attributable to intervention (cost difference after – cost difference before) 

81. For studies reporting the total cost of inappropriate antimicrobial prophylaxis avoided, record the 

following data: 

(Note: for simple before-after studies, enter all data in “intervention” boxes) 

o Exact units of measurement 

o Total costs in CONTROL group before intervention 

o Total costs in CONTROL group after intervention 

o Cost difference before intervention (intervention – control) 

o Total costs in INTERVENTION group before intervention 

o Total costs in INTERVENTION group after intervention 

o Cost difference after intervention (intervention – control) 

o Net change in costs attributable to intervention (cost difference after – cost difference before) 

82. For studies reporting the total cost of interventions to prevent surgical site infections, record the 

following data: 

(Note: for simple before-after studies, enter all data in “intervention” boxes) 

o Exact units of measurement 

o Total costs in CONTROL group before intervention 

o Total costs in CONTROL group after intervention 

o Cost difference before intervention (intervention – control) 

o Total costs in INTERVENTION group before intervention 

o Total costs in INTERVENTION group after intervention 

o Cost difference after intervention (intervention – control) 

o Net change in costs attributable to intervention (cost difference after – cost difference before) 

Studies addressing Central Line Infections 

83. Did the study address Central Line Infections? 

o Yes 

o No (go to question 104) 

84. What were the outcome types? (check all that apply) 

• Central line infection rate 

• Compliance with Hand hygiene 

• Compliance with maximal sterile barrier precautions 

• Compliance with appropriate catheter site selection 

• Compliance with use of chlorhexidine skin prophylaxis 
B15

• Compliance with prompt removal of unnecessary catheters 

• Compliance with a clinical guideline for preventing central line infections (use this if study 

mandated an explicit guideline, checklist or “bundle” incorporating more than one of the 

interventions described above) 

• Costs associated with intervention 

• Adverse effects of the intervention [specify] 

• Provider satisfaction with QI strategy 

• Not sure or other (describe) 

85. If the study reported central line infection rates, did the study define infections according to Centers 

for Disease Control (CDC) or National Nosocomial Infection Surveillance System (NNIS) protocols? 

• Yes 

• No (enter definition of CLABSI as documented in article) 

• Does not apply – did not report infection rates 

86. If the study reported central line infection rates, for which specific types of central lines were 

infections measured? 

o All central lines 

o Only non-tunnelled central lines 

o Not specified 

o Other or unclear (enter relevant information from article) 

o Does not apply – did not report infection rates 

87. For studies reporting data in the form of CLABSI rate, provide the following data for the CONTROL 

group. If data is missing, record “NR” 

o Exact units of measurement 

o Infection rate prior to intervention (s) 

o Infection rate after intervention(s) (Not applicable to SBA studies) 

o Percentage change in infection rate (Not applicable to SBA studies) 

o Does not apply – simple before-after study 

88. For studies reporting data in the form of CLABSI rate, provide the following data for the 

INTERVENTION group; if data is missing, record “NR”. Note: for simple before-after studies, enter 

“before” data in “prior to intervention” box and “after” data in “after intervention” box 

o Exact units of measurement 

o Infection rate prior to intervention 

o Infection rate after intervention 

89. Enter any data on CLABSI rates not abstracted above here: 

o Control group before intervention 

o Control group after intervention 

o Intervention group before intervention 

o Intervention group after intervention 

90. For studies reporting data in the form of adherence to hand hygiene, provide the following data for 

the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 
B16

91. For studies reporting data in the form of adherence to hand hygiene, provide the following data for the 

INTERVENTION group; if data is missing, record “NR”. Note: enter all data for simple before-after 

studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 

92. For studies reporting data in the form of adherence to appropriate use of maximal sterile barrier 

precautions, provide the following data for the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

93. For studies reporting data in the form of adherence to appropriate catheter site selection, provide the 

following data for the INTERVENTION group; if data is missing, record “NR”. Note: enter all data for 

simple before-after studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 

94. For studies reporting data in the form of adherence to use of chlorhexidine for skin disinfection, 

provide the following data for the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

95. For studies reporting data in the form of adherence to protocols for prompt removal of unnecessary 

catheters, provide the following data for the INTERVENTION group; if data is missing, record “NR”. Note: 

enter all data for simple before-after studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 

96. For studies reporting data in the form of adherence to an explicit clinical guideline for preventing 

CLABSI, provide the following data for the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

97. For studies reporting data in the form of adherence to an explicit clinical guideline for preventing 

CLABSI, provide the following data for the INTERVENTION group; if data is missing, record “NR”. Note: 

enter all data for simple before-after studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 
B17

98. Provide the following data for other types of measurements of adherence to preventive interventions 

not abstracted above: 

o Specific preventive intervention and units of measurement 

o Value in CONTROL group before intervention 

o Value in CONTROL group after intervention 

o Value in INTERVENTION group before intervention 

o Value in INTERVENTION group after intervention 

Measures of costs 

Note: cost outcomes should be abstracted only if the study also has usable data for one of the primary 

outcomes (nosocomial infection rate or provider compliance rate) 

99. For studies reporting cost outcomes, what specific measures were used? 

o Total cost of CLABSI to hospital or health system 

o Total cost of interventions to prevent CLABSI 

o Other (describe) 

o No measurement of costs 

100. For studies reporting the total cost of CLABSI, record the following data: 

(Note: for simple before-after studies, enter all data in “intervention” boxes) 

o Exact units of measurement 

o Total costs in CONTROL group before intervention 

o Total costs in CONTROL group after intervention 

o Cost difference before intervention (intervention – control) 

o Total costs in INTERVENTION group before intervention 

o Total costs in INTERVENTION group after intervention 

o Cost difference after intervention (intervention – control) 

o Net change in costs attributable to intervention (cost difference after – cost difference before) 

101. For studies reporting the total cost of interventions to prevent CLABSI, record the following data: 

(Note: for simple before-after studies, enter all data in “intervention” boxes) 

o Exact units of measurement 

o Total costs in CONTROL group before intervention 

o Total costs in CONTROL group after intervention 

o Cost difference before intervention (intervention – control) 

o Total costs in INTERVENTION group before intervention 

o Total costs in INTERVENTION group after intervention 

o Cost difference after intervention (intervention – control) 

o Net change in costs attributable to intervention (cost difference after – cost difference before) 

Ventilator-Associated Pneumonia 

102. Did the study address Ventilator Associated Pneumonia (VAP)? 

o Yes 

o No (go to question 121) 

103. What were the outcome types? (check all that apply) 

• VAP rate 

• Compliance with Hand hygiene 

• Compliance with head of bed elevation 

• Compliance with protocols to assess readiness for ventilator weaning (includes daily lifting of 

sedation) 
B18

• Compliance with a clinical guideline for preventing VAP (use this if study mandated an explicit 

guideline, checklist or “bundle” incorporating more than one of the interventions described above) 

• Costs associated with intervention 

• Adverse effects of the intervention [specify] 

• Provider satisfaction with QI strategy 

• Not sure or other (describe) 

104. If the study reported VAP rates, did the study use invasive methods to establish the diagnosis of 

VAP? (check all that apply) 

• Yes – used bronchoalveolar lavage (BAL) 

• Yes – used sampling with protected specimen brush (PSB) 

• No – used clinical criteria only (specify criteria, e.g., new infiltrate on chest x-ray, fever, elevated 

white blood cell count) 

• Study used both invasive and clinical criteria to diagnose VAP 

• Not clear or not specified 

• Does not apply – did not report VAP rates 

105. For studies reporting data in the form of VAP rate, provide the following data for the CONTROL 

group. If data is missing, record “NR” 

o Exact units of measurement 

o Infection rate prior to intervention (s) 

o Infection rate after intervention(s) (Not applicable to SBA studies) 

o Percentage change in infection rate (Not applicable to SBA studies) 

o Does not apply – simple before-after study 

106. For studies reporting data in the form of VAP rate, provide the following data for the INTERVENTION 

group; if data is missing, record “NR”. Note: for simple before-after studies, enter “before” data in “prior 

to intervention” box and “after” data in “after intervention” box 

o Exact units of measurement 

o Infection rate prior to intervention 

o Infection rate after intervention 

107. Enter any data on VAP rates not abstracted above here: 

o Control group before intervention 

o Control group after intervention 

o Intervention group before intervention 

o Intervention group after intervention 

108. For studies reporting data in the form of adherence to hand hygiene, provide the following data for 

the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

109. For studies reporting data in the form of adherence to hand hygiene, provide the following data for 

the INTERVENTION group; if data is missing, record “NR”. Note: enter all data for simple before-after 

studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 
B19

110. For studies reporting data in the form of adherence to head of the bed elevation, provide the 

following data for the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

111. For studies reporting data in the form of adherence to head of the bed elevation, provide the 

following data for the INTERVENTION group; if data is missing, record “NR”. Note: enter all data for 

simple before-after studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 

112. For studies reporting data in the form of adherence to an explicit clinical guideline for preventing 

VAP, provide the following data for the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

113. For studies reporting data in the form of adherence to an explicit clinical guideline for preventing 

VAP, provide the following data for the INTERVENTION group; if data is missing, record “NR”. Note: 

enter all data for simple before-after studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 

114. Provide the following data for other types of measurements of adherence to preventive interventions 

not abstracted above: 

o Specific preventive intervention and units of measurement 

o Value in CONTROL group before intervention 

o Value in CONTROL group after intervention 

o Value in INTERVENTION group before intervention 

o Value in INTERVENTION group after intervention 

Measures of costs 

Note: cost outcomes should be abstracted only if the study also has usable data for one of the primary 

outcomes (nosocomial infection rate or provider compliance rate) 

115. For studies reporting cost outcomes, what specific measures were used? 

o Total cost of VAP to hospital or health system 

o Total cost of interventions to prevent VAP 

o Other (describe) 

o No measurement of costs 

116. For studies reporting the total cost of VAP, record the following data: 

(Note: for simple before-after studies, enter all data in “intervention” boxes) 

o Exact units of measurement 

o Total costs in CONTROL group before intervention 

o Total costs in CONTROL group after intervention 

o Cost difference before intervention (intervention – control) 
B20

o Total costs in INTERVENTION group before intervention 

o Total costs in INTERVENTION group after intervention 

o Cost difference after intervention (intervention – control) 

o Net change in costs attributable to intervention (cost difference after – cost difference before) 

117. For studies reporting the total cost of interventions to prevent VAP, record the following data: 

(Note: for simple before-after studies, enter all data in “intervention” boxes) 

o Exact units of measurement 

o Total costs in CONTROL group before intervention 

o Total costs in CONTROL group after intervention 

o Cost difference before intervention (intervention – control) 

o Total costs in INTERVENTION group before intervention 

o Total costs in INTERVENTION group after intervention 

o Cost difference after intervention (intervention – control) 

o Net change in costs attributable to intervention (cost difference after – cost difference before) 

Urinary Catheter-associated UTI 

118. Did the study address urinary catheter-associated UTI (UTI)? 

o Yes 

o No (go to question xx) 

119. What were the outcome types? (check all that apply) 

• Rate of symptomatic urinary tract infection 

• Rate of asymptomatic bacteriuria 

• Rate of use of indwelling urinary catheters 

• Compliance with Hand hygiene 

• Compliance with prompt removal of unnecessary catheters 

• Compliance with aseptic insertion and catheter care 

• Compliance with a clinical guideline for preventing UTI (use this if study mandated an explicit 

guideline, checklist or “bundle” incorporating more than one of the interventions described above) 

• Costs associated with intervention 

• Adverse effects of the intervention [specify] 

• Provider satisfaction with QI strategy 

• Not sure or other (describe) 

120. If the study reported rates of symptomatic UTI, did the study define infections according to Centers 

for Disease Control (CDC) or National Nosocomial Infection Surveillance System (NNIS) protocols? 

• Yes 

• No (enter definition of UTI as documented in article) 

• Does not apply – did not report rates of symptomatic UTI 

121. If the study reported rates of asymptomatic bacteriuria, how was this defined? 

o Enter definition of asymptomatic bacteriuria[text box] 

o Does not apply – did not report rates of asymptomatic bacteriuria 
B21

122. For studies reporting symptomatic UTI rate, provide the following data for the CONTROL group. If 

data is missing, record “NR” 

o Exact units of measurement 

o Infection rate prior to intervention (s) 

o Infection rate after intervention(s) (Not applicable to SBA studies) 

o Percentage change in infection rate (Not applicable to SBA studies) 

o Does not apply – simple before-after study 

123. For studies reporting symptomatic UTI rate, provide the following data for the INTERVENTION 

group; if data is missing, record “NR”. Note: for simple before-after studies, enter “before” data in “prior 

to intervention” box and “after” data in “after intervention” box 

o Exact units of measurement 

o Infection rate prior to intervention 

o Infection rate after intervention 

124. For studies reporting rate of asymptomatic bacteriuria, provide the following data for the CONTROL 

group. If data is missing, record “NR” 

o Exact units of measurement 

o Infection rate prior to intervention (s) 

o Infection rate after intervention(s) (Not applicable to SBA studies) 

o Percentage change in infection rate (Not applicable to SBA studies) 

o Does not apply – simple before-after study 

125. For studies reporting rate of asymptomatic bacteriuria, provide the following data for the 

INTERVENTION group; if data is missing, record “NR”. Note: for simple before-after studies, enter 

“before” data in “prior to intervention” box and “after” data in “after intervention” box 

o Exact units of measurement 

o Infection rate prior to intervention 

o Infection rate after intervention 

126. Enter any data on rate of symptomatic UTI or asymptomatic bacteriuria not abstracted above here: 

o Exact units of measurement 

o Control group before intervention 

o Control group after intervention 

o Intervention group before intervention 

o Intervention group after intervention 

127. For studies reporting rate of use of indwelling urinary catheters, provide the following data for the 

CONTROL group. If data is missing, record “NR” 

o Exact units of measurement 

o Rate of use of catheters prior to intervention (s) 

o Rate of use of catheter after intervention(s) (Not applicable to SBA studies) 

o Percentage change in rate of use of catheters (Not applicable to SBA studies) 

o Does not apply – simple before-after study 

128. For studies reporting rate of use of indwelling urinary catheters, provide the following data for the 

INTERVENTION group; if data is missing, record “NR”. Note: for simple before-after studies, enter 

“before” data in “prior to intervention” box and “after” data in “after intervention” box 

o Exact units of measurement 

o Infection rate prior to intervention 

o Infection rate after intervention 

129. For studies reporting data in the form of adherence to hand hygiene, provide the following data for 

the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 
B22

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

130. For studies reporting data in the form of adherence to hand hygiene, provide the following data for 

the INTERVENTION group; if data is missing, record “NR”. Note: enter all data for simple before-after 

studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 

131. For studies reporting data in the form of adherence to aseptic catheter care, provide the following 

data for the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

132. For studies reporting data in the form of adherence to aseptic catheter care, provide the following 

data for the INTERVENTION group; if data is missing, record “NR”. Note: enter all data for simple 

before-after studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 

133. For studies reporting data in the form of adherence to an explicit clinical guideline for preventing 

UTI, provide the following data for the CONTROL group; if data is missing, record “NR” 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate before intervention 

o Percentage change in compliance rate 

o Not applicable – simple before-after study 

134. For studies reporting data in the form of adherence to an explicit clinical guideline for preventing UTI, 

provide the following data for the INTERVENTION group; if data is missing, record “NR”. Note: enter all 

data for simple before-after studies here 

o Exact units of measurement 

o Adherence rate before intervention 

o Adherence rate after intervention 

o Percentage change in compliance rate 

135. Provide the following data for other types of measurements of adherence to preventive interventions 

not abstracted above: 

o Specific preventive intervention and units of measurement 

o Value in CONTROL group before intervention 

o Value in CONTROL group after intervention 

o Value in INTERVENTION group before intervention 

o Value in INTERVENTION group after intervention 

Measures of costs 

Note: cost outcomes should be abstracted only if the study also has usable data for one of the primary 

outcomes (nosocomial infection rate or provider compliance rate) 
B23

136. For studies reporting cost outcomes, what specific measures were used? 

o Total cost of UTI to hospital or health system 

o Total cost of interventions to prevent UTI 

o Other (describe) 

o No measurement of costs 

137. For studies reporting the total cost of UTI, record the following data: 

(Note: for simple before-after studies, enter all data in “intervention” boxes) 

o Exact units of measurement 

o Total costs in CONTROL group before intervention 

o Total costs in CONTROL group after intervention 

o Cost difference before intervention (intervention – control) 

o Total costs in INTERVENTION group before intervention 

o Total costs in INTERVENTION group after intervention 

o Cost difference after intervention (intervention – control) 

o Net change in costs attributable to intervention (cost difference after – cost difference before) 

138. For studies reporting the total cost of interventions to prevent UTI, record the following data: 

(Note: for simple before-after studies, enter all data in “intervention” boxes) 

o Exact units of measurement 

o Total costs in CONTROL group before intervention 

o Total costs in CONTROL group after intervention 

o Cost difference before intervention (intervention – control) 

o Total costs in INTERVENTION group before intervention 

o Total costs in INTERVENTION group after intervention 

o Cost difference after intervention (intervention – control) 

o Net change in costs attributable to intervention (cost difference after – cost difference before) 

For all studies 

Provider satisfaction with intervention 

Note: provider satisfaction should be abstracted only if the study also has usable data for one of the 

primary outcomes (nosocomial infection rate or provider compliance rate) 

139. For studies reporting data on PROVIDER satisfaction with the intervention, provide the following 

data; if data is missing,record “NR” 

o No measure of provider satisfaction 

o Percent satisfaction in CONTROL group after intervention 

o Percent satisfaction in INTERVENTION group after intervention 

o Absolute difference (intervention – control) 

Adverse events associated with the intervention 

Note: adverse events should be abstracted only if the study also has usable data for one of the primary 

outcomes (nosocomial infection rate or provider compliance rate) 

140. Did the study report data on adverse events associated with the intervention? 

o Yes (specify) 

o No 

141. If the study reported data on adverse events associated with the intervention, enter data here: [text 

box] 
B24

142. Use textbox to state any important study results or concerns not documented above. [text box]
C1

Appendix C. Listing of Excluded Studies 

Abdel-Razek A. Nosocomial infections in ventilated patients. Middle East J 

Anesthesiol. 1992;11(4):369-79. 

Not an evaluation of a 

QI intervention 

Abi-Said D, Raad I, Umphrey J, et al. Infusion therapy team and dressing changes of 

central venous catheters. Infect Control Hosp Epidemiol. 1999;20(2):101-5. 

Not an evaluation of a 

QI intervention 

Adams-Chapman I, Stoll BJ. Prevention of nosocomial infections in the neonatal 

intensive care unit. Curr Opin Pediatr. 2002;14(2):157-64. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Alcohol for hand hygiene: new comparative studies add to the evidence base. Can 

Commun Dis Rep. 2003;29(1):4-6. 

Not an evaluation of a 

QI intervention 

Al-Hashemy AM, Seleem MI, Khan ZA, et al. Postoperative wound infection in 

surgical procedures. Saudi Med J. 2004;25(8):1122-3. 

Not an evaluation of a 

QI intervention 

Allen SD, Conger KB. Serratia marcescens infection of the urinary tract: a 

nosocomial infection. J Urol. 1969;101(4):621-3. 

Not an evaluation of a 

QI intervention 

Alpert JJ, Heagarty MC, Robertson L, et al. Effective use of comprehensive pediatric 

care. Utilization of health resources. American Journal of Diseases of Children. 

1968;116(5):529. 

Excluded topic 

Alvarado CJ, Reichelderfer M. APIC guideline for infection prevention and control in 

flexible endoscopy. Association for Professionals in Infection Control. Am J Infect 

Control. 2000;28(2):138-55. 

Excluded topic 

Aly H, Herson V, Duncan A, et al. Is bloodstream infection preventable among 

premature infants? A tale of two cities. Pediatrics. 2005;115(6):1513-8. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Amer FA, Mohtady HA, el-Behedy IM, et al. Bacteria of nosocomial urinary tract 

infections at a university hospital in Egypt: identification and associated risk factors. 

Infect Control Hosp Epidemiol. 2004;25(11):895-7. 

Not an evaluation of a 

QI intervention 

Andersen C, Hart J, Vemgal P, et al. Prospective evaluation of a multi-factorial 

prevention strategy on the impact of nosocomial infection in very-low-birthweight 

infants. J Hosp Infect 2005; 61:162-7. 

Other 

Andriole VT. Hospital acquired urinary infections and the indwelling catheter. Urol 

Clin North Am. 1975;2(3):451-69. 

Not an evaluation of a 

QI intervention 

Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett. 2004;2(20):27-32. Not an evaluation of a 

QI intervention 

APIC position paper: prevention of device-mediated bloodborne infections to health 

care workers. Association for Professionals in Infection Control and Epidemiology, 

Inc. Am J Infect Control. 1998;26(6):578-80. 

Not an evaluation of a 

QI intervention 

Aronow HU, Bolton LB, Aydin C, et al. Patient focused care: evaluating the dual 

goals of quality improvement and cost reduction abstract. AHSR & FHSR Annual 

Meeting Abstract Book. 1994;11:8. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Austin TW, Austin MA, Coleman B, et al. Total knee replacement surgery and 

surgical site infection: a prospective audit. Can J Surg. 2004;47(2):145. 

Not an evaluation of a 

QI intervention 

Avery CM, Jamieson N, Calne RY. Effective administration of heparin and antibiotic 

prophylaxis. Br J Surg. 1995;82(8):1136-7. 

Not an evaluation of a 

QI intervention 

Babcock HM. Surveillance for surgical-site infections: it''s getting better all the time. 

Infect Control Hosp Epidemiol. 2003;24(10):722-3. 

Not an evaluation of a 

QI intervention 
C2

Bagnulo H. Principles and problems in surgical infections. Introduction. Surg Infect 

(Larchmt). 2001;2 Suppl 1:S1-2. 

Not an evaluation of a 

QI intervention 

Bailey DR, Riedel DC. Study evaluates Blue Cross recertification experiment. 

Modern Hospital. 1968;110(2):106. 

Excluded topic 

Ball C. Medical devices and their role in the incidence of ventilator-associated 

pneumonia--challenging some sacred cows! Intensive Crit Care Nurs. 

2005;21(3):131-4. 

Not an evaluation of a 

QI intervention 

Bard biocath hydrophilic-coated Foley catheters. Health Devices. 1988;17(2):69. Not an evaluation of a 

QI intervention 

Barson AJ. Fatal Pseudomonas aeruginosa bronchopneumonia in a children''s 

hospital. Arch Dis Child. 1971;46(245):55-60. 

Not an evaluation of a 

QI intervention 

Bartlett RC. Control of hospital-associated infection. Prog Clin Pathol. 1972;4:259-

82. 

Not an evaluation of a 

QI intervention 

Bates DW, Makary MA, Teich JM, et al. Asking residents about adverse events in a 

computer dialogue: how accurate are they? Jt Comm J Qual Improv. 

1998;24(4):197-202. 

Not an evaluation of a 

QI intervention 

Bishop-Kurylo D. The clinical experience of continuous quality improvement in the 

neonatal intensive care unit. J Perinat Neonatal Nurs. 1998;12(1):51-7. 

No eligible outcomes 

Blenkharn JJ. Prevention of bacteriuria during urinary catheterization of patients in 

an intensive care unit: evaluation of the 'Ureofix 500' closed drainage system. J Hosp 

Infect. 1985;6(2):187-93. 

Not an evaluation of a 

QI intervention 

Bleyer AJ, Mason L, Russell G, et al. A randomized, controlled trial of a new vascular 

catheter flush solution (minocycline-EDTA) in temporary hemodialysis access. Infect 

Control Hosp Epidemiol. 2005;26(6):520-4. 

Not an evaluation of a 

QI intervention 

Bloom B, Craddock A, Delmore P, et al. Reducing acquired infections in the NICU: 

observing and implementing meaningful differences in process between high and 

low acquired infection rate centers. Journal of Perinatology. 2003;23(6):489. 

No eligible outcomes 

Bodiwala GG, George TK. Surgical gloves during wound repair in the accident-andemergency department. Lancet. 1982;2(8289):91-2. Not an evaluation of a 

QI intervention 

Boelle PY, Golliot F, Valleron AJ. A framework for benchmarking hospital 

performance: application to surgical site infection. Stud Health Technol Inform. 

2003;95:777-82. 

Not an evaluation of a 

QI intervention 

Bond P, Harris C. Best practice in urinary catheterisation and catheter care. Nurs 

Times. 2005;101(8):54, 6, 8. 

Not an evaluation of a 

QI intervention 

Bonten MJ, Gaillard CA, Hulst Rvd, et al. Intermittent enteral feeding: the influence 

on respiratory and digestive tract colonization in mechanically ventilated intensivecare-unit patients. Am J Respir Crit Care Med. 1996;154(2 Pt 1):394-9. 

Not an evaluation of a 

QI intervention 

Bonten MJ, Gaillard CA, Tiel FHv, et al. Colonization and infection with Enterococcus 

faecalis in intensive care units: the role of antimicrobial agents. Antimicrob Agents 

Chemother. 1995;39(12):2783-6. 

Not an evaluation of a 

QI intervention 

Booth AL, Weeks RM, Hutcheson RH, et al. A statewide characterization of hospital 

infection control practices and practitioners. Infect Control. 1980;1(4):227-32. 

Not an evaluation of a 

QI intervention 

Borlu M, Utas S. Pyoderma gangrenosum after cholecystectomy. J Eur Acad 

Dermatol Venereol. 2001;15(2):185-6. 

Not an evaluation of a 

QI intervention 
C3

Boyce JM, Jackson MM, Pugliese G, et al. Methicillin-resistant Staphylococcus 

aureus (MRSA): a briefing for acute care hospitals and nursing facilities. The AHA 

Technical Panel on Infections Within Hospitals. Infect Control Hosp Epidemiol. 

1994;15(2):105-15. 

Not an evaluation of a 

QI intervention 

Boyce TG. Utility of peripheral venous blood cultures in patients with central venous 

catheters. Pediatr Infect Dis J. 2000;19(5):491-2. 

Not an evaluation of a 

QI intervention 

Brock VB. The impact of performance feedback on handwashing behaviors. The 

University of Alabama at Birmingham ** D 2002. 

Other: article not 

available 

Brook AD, Ahrens TS, Schaiff R, et al. Effect of a nursing-implemented sedation 

protocol on the duration of mechanical ventilation see comments. Critical Care 

Medicine. 1999;27(12):2609. 

Not an evaluation of a 

QI intervention 

Brown SM, Lubimova AV, Khrustalyeva NM, et al. Use of an alcohol-based hand rub 

and quality improvement interventions to improve hand hygiene in a Russian 

neonatal intensive care unit. Infection Control & Hospital Epidemiology. 

2003;24(3):172. 

Excluded topic 

Brox N, Ghazarian P. Reducing surgical site infection through process improvement 

initiatives. Kans Nurse. 2004;79(4):10-1. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Brun-Buisson C. New technologies and infection control practices to prevent 

intravascular catheter-related infections. Am J Respir Crit Care Med. 

2001;164(9):1557-8. 

Not an evaluation of a 

QI intervention 

Brun-Buisson C. Nosocomial pneumonia during mechanical ventilation. Thorax. 

1996;51(7):771-2. 

Not an evaluation of a 

QI intervention 

Brunelle D. Impact of a dedicated infusion therapy team on the reduction of catheterrelated nosocomial infections. J Infus Nurs 2003; 26:362-6. Other: interventions 

did not include our 

target interventions 

Carling P, Fung T, Killion A, et al. Favorable impact of a multidisciplinary antibiotic 

management program conducted during 7 years. Infection Control & Hospital 

Epidemiology. 2003;24(9):699. 

No eligible outcomes 

Carroll P. Preventing nosocomial pneumonia. Rn. 1998;61(6):44-7; quiz 8. Not an evaluation of a 

QI intervention 

Casey J, Davies J. A nurse led central line insertion service. Edtna Erca J. 

2003;29(4):203-5. 

Not an evaluation of a 

QI intervention 

Cerwenka H, Wolf G, Mischinger HJ, et al. Natural killer cell deficiency and severe 

wound infection after thyroid surgery. Eur J Surg. 2001;167(10):792-4. 

Not an evaluation of a 

QI intervention 

Chan YM, Ngai SW, Hon E, et al. Could the incidence of postoperative urinary tract 

infection be reduced by reversing the sequence of vaginal cleansing and urethral 

catheterization? J Hosp Infect. 2000;46(1):67-72. 

Not an evaluation of a 

QI intervention 

Children''s hospitals prevent post-surgical infections. Perform Improv Advis. 

2005;9(6):61-3. 

Not an evaluation of a 

QI intervention 

Childs SJ. Perioperative prevention of infection in genitourinary surgery. Antibiot 

Chemother. 1985;33:1-29. 

Not an evaluation of a 

QI intervention 

Chinn R, Dembitsky W, Eaton L, et al. Multicenter experience: prevention and 

management of left ventricular assist device infections. Asaio J. 2005;51(4):461-70. 

Not an evaluation of a 

QI intervention 

Chonmide ON, McMahon M, Gillen P, et al. Non-specialist paediatric surgery--where 

should it be performed? Ir Med J. 1999;92(7):439. 

Not an evaluation of a 

QI intervention 

''Close the loop'' in QI for ASCs. OR Manager. 2000;16(3):17, 20. Not an evaluation of a 

QI intervention 
C4

Cobb DK, High KP, Sawyer RG, et al. A controlled trial of scheduled replacement of 

central venous and pulmonary-artery catheters. N Engl J Med. 1992;327(15):1062-

8. 

Not an evaluation of a 

QI intervention 

Cohran J, Larson E, Roach H, et al. Effect of intravascular surveillance and 

education program on rates of nosocomial bloodstream infections. Heart Lung. 

1996;25(2):161-4. 

Not an evaluation of a 

QI intervention 

Collier C, Miller DP, Borst M. Community hospital surgeon-specific infection rates. 

Infect Control. 1987;8(6):249-54. 

Not an evaluation of a 

QI intervention 

Collis DK, Steinhaus K. Total hip replacement without deep infection in a standard 

operating room. J Bone Joint Surg Am. 1976;58(4):446-50. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Collopy BT, Hart JA, Hooper JC, et al. An inter-hospital criteria audit of infection in 

total hip-joint replacement surgery. Aust Clin Rev. 1984(13):19-21. 

Not an evaluation of a 

QI intervention 

Complications of colonic and rectal surgery: discussion. Dis Colon Rectum. 

1973;16(1):23-8. 

Not an evaluation of a 

QI intervention 

Controlling antimicrobial resistance. An integrated action plan for Canadians. Can 

Commun Dis Rep. 1997;23 Suppl 7:i-iv, 1-32, i-iv, 1-. 

Not an evaluation of a 

QI intervention 

Couzigou C, Lamory J, Salmon-Ceron D, et al. Short peripheral venous catheters: 

effect of evidence-based guidelines on insertion, maintenance and outcomes in a 

university hospital. J Hosp Infect. 2005;59(3):197-204. 

Excluded topic 

Crow S. Infection control in the emergency room. Nurs Clin North Am. 

1980;15(4):869-82. 

Not an evaluation of a 

QI intervention 

Crummy V. Hospital-acquired urinary tract infection. Nurs Times. 1985;81(23):suppl 

7-12. 

Not an evaluation of a 

QI intervention 

Cunha BA. Diagnosis and prevention of intravenous central line-associated 

infections. Heart Lung. 1995;24(4):261-2. 

Not an evaluation of a 

QI intervention 

Cunha BA. Nosocomial urinary tract infections. Heart Lung. 1982;11(6):545-51. Not an evaluation of a 

QI intervention 

Dagan O, Cox PN, Ford-Jones L, et al. Nosocomial infection following cardiovascular 

surgery: comparison of two periods, 1987 vs. 1992. Crit Care Med 1999; 27:104-8. 

Other: QI intervention 

not described 

Dancer SJ, Crawford A. Keeping MRSA out of a district general hospital. J Hosp 

Infect. 1999;43 Suppl:S19-27. 

No eligible outcomes 

Dann AI. Central line sepsis in children with gastrointestinal disorders. Gastroenterol 

Nurs. 1994;16(6):259-63. 

Not an evaluation of a 

QI intervention 

Dart CR, Cooke RP. Central venous catheter care. Br J Hosp Med. 1995;53(3):113-

4. 

Not an evaluation of a 

QI intervention 

Daschner F. Stress ulcer prophylaxis and the risk of nosocomial pneumonia in 

artificially ventilated patients. Eur J Clin Microbiol. 1987;6(2):129-31. 

Not an evaluation of a 

QI intervention 

Davis KJ, Evans SL, Campbell RS, et al. Heat-moisture exchangers and risk of 

nosocomial pneumonia. Infect Control Hosp Epidemiol. 2000;21(9):618. 

Not an evaluation of a 

QI intervention 

de Gentile A, Rivas N, Sinkowitz-Cochran R, et al. Nosocomial infections in a 

children's hospital in Argentina: impact of a unique infection control intervention 

program. Infection Control & Hospital Epidemiology. 2001;22(12):762. 

No eligible outcomes 

Degroot J. Indwelling catheters. Am J Nurs. 1975;75(3):448-9. Not an evaluation of a 

QI intervention 
C5

DeLise DC, Leasure AR. Benchmarking: measuring the outcomes of evidence-based 

practice. Outcomes Manag Nurs Pract. 2001;5(2):70-4. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Dickerson N, Horton P, Smith S, et al. Clinically significant central venous catheter 

infections in a community hospital: association with type of dressing. J Infect Dis. 

1989;160(4):720-2. 

Not an evaluation of a 

QI intervention 

DiConsiglio J. Combine & conquer. Mater Manag Health Care. 2004;13(10):32-4. Not an evaluation of a 

QI intervention 

Dimick JB, Pronovost PJ, Heitmiller RF, et al. Intensive care unit physician staffing is 

associated with decreased length of stay, hospital cost, and complications after 

esophageal resection. Crit Care Med. 2001;29(4):753-8. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Dinc L, Erdil F. The effectiveness of an educational intervention in changing nursing 

practice and preventing catheter-related infection for patients receiving total 

parenteral nutrition. International Journal of Nursing Studies. 2000;37(5):371. 

No eligible outcomes 

Dittmer ID, Tomson CR. Pulmonary abscess complicating central venous 

hemodialysis catheter infection. Clin Nephrol. 1998;49(1):66. 

Not an evaluation of a 

QI intervention 

Dittmer ID. Infections associated with central venous catheterisation for 

plasmapheresis. Aust N Z J Med. 1998;28(6):835. 

Not an evaluation of a 

QI intervention 

dos Santos CC, Zhang H, Slutsky AS. From bench to bedside: bacterial growth and 

cytokines. Crit Care. 2002;6(1):4-6. 

Not an evaluation of a 

QI intervention 

Doughty DB. Preventing and managing surgical wound dehiscence. Home Healthc 

Nurse. 2004;22(6):364-7. 

Not an evaluation of a 

QI intervention 

Drakulovic MB, Djokic D, Torres A. Colonization with Pseudomonas aeruginosa in 

critically ill patients and measures for its prevention. Neth J Med. 1999;55(3):100-2. 

Not an evaluation of a 

QI intervention 

Dries DJ, McGonigal MD, Malian MS, et al. Protocol-driven ventilator weaning 

reduces use of mechanical ventilation, rate of early reintubation, and ventilatorassociated pneumonia. J Trauma. 2004;56(5):943-51; discussion 51-2. 

Not an evaluation of a 

QI intervention 

Early intervention prevents pneumonia in high-risk populations. Med Manag Netw. 

1999;7(2):6-9. 

Not an evaluation of a 

QI intervention 

Earsing KA, Hobson DB, White KM. Best-practice protocols: preventing central line 

infection. Nurs Manage 2005; 36:18-24. 

Duplicate publication 

East TD, Heermann LK, Bradshaw RL, et al. Efficacy of computerized decision 

support for mechanical ventilation: results of a prospective multi-center randomized 

trial. Proceedings / AMIA Annual Symposium. 1999:251. 

Excluded topic 

Eggimann P, Hugonnet S, Sax H, et al. Long-term reduction of vascular accessassociated bloodstream infection. Ann Intern Med 2005; 142:875-6. Duplicate publication 

Elward AM. Pediatric ventilator-associated pneumonia. Pediatr Infect Dis J. 

2003;22(5):445-6. 

Not an evaluation of a 

QI intervention 

Evans AT. Nosocomial infections and the urologist. J Urol. 1974;111(6):813-6. Not an evaluation of a 

QI intervention 

Everitt DE, Soumerai SB, Avorn J, et al. Changing surgical antimicrobial prophylaxis 

practices through education targeted at senior department leaders. Infection Control 

& Hospital Epidemiology 1990; 11:578. 

Other: no baseline 

data reported 

Fanning C, Johnston BL, MacDonald S, et al. Postdischarge surgical site infection 

surveillance. Can J Infect Control. 1995;10(3):75-9. 

Not an evaluation of a 

QI intervention 
C6

Fanning MF. Reducing postoperative pulmonary complications in cardiac surgery 

patients with the use of the best evidence. J Nurs Care Qual. 2004;19(2):95-9. 

Excluded topic 

Farley JE, Srinivasan A, Richards A, et al. Handheld computer surveillance: shoeleather epidemiology in the "palm" of your hand. Am J Infect Control. 

2005;33(8):444-9. 

Not an evaluation of a 

QI intervention 

Ferraz EM, Ferraz AA, Coelho HS, et al. Postdischarge surveillance for nosocomial 

wound infection: does judicious monitoring find cases? Am J Infect Control. 

1995;23(5):290-4. 

Not an evaluation of a 

QI intervention 

Ferrer R, Artigas A. Clinical review: non-antibiotic strategies for preventing ventilatorassociated pneumonia. Crit Care. 2002;6(1):45-51. Not an evaluation of a 

QI intervention 

Field J. Prevention of infection: central venous catheters. Nurs Stand. 

2002;16(38):40-4. 

Not an evaluation of a 

QI intervention 

Filippo AD, Gaudio ARD. Device-related infections in critically ill patients. Part II: 

Prevention of ventilator-associated pneumonia and urinary tract infections. J 

Chemother. 2003;15(6):536-42. 

Not an evaluation of a 

QI intervention 

Flanders E, Hinnant JR. Ambulatory surgery postoperative wound surveillance. Am J 

Infect Control. 1990;18(5):336-9. 

Not an evaluation of a 

QI intervention 

Forchielli ML, Lo CW, Richardson D, et al. Central venous line related bacteremia 

during total parenteral nutrition and/or chemotherapy infusions in children. Ann Ig. 

1997;9(1):35-40. 

Not an evaluation of a 

QI intervention 

Forster DH, Krause G, Gastmeier P, et al. Can quality circles improve hospitalacquired infection control? J Hosp Infect. 2000;45(4):302-10. No eligible outcomes 

Fraenkel D, Rickard C, Thomas P, et al. A prospective, randomized trial of 

rifampicin-minocycline-coated and silver-platinum-carbon-impregnated central 

venous catheters. Crit Care Med. 2006;34(3):668-75. 

Not an evaluation of a 

QI intervention 

Franklin CM. Does ICU care determine the outcome of caring for patients with 

pneumococcal bacteremia? Chest. 1995;108(5):1475. 

Not an evaluation of a 

QI intervention 

Fridkin SK, Gaynes RP. Antimicrobial resistance in intensive care units. Clin Chest 

Med. 1999;20(2):303-16, viii. 

Not an evaluation of a 

QI intervention 

Fridkin SK. Increasing prevalence of antimicrobial resistance in intensive care units. 

Crit Care Med. 2001;29(4 Suppl):N64-8. 

Not an evaluation of a 

QI intervention 

Friedewald M, Elwin C. New graduate nurses and infection control: knowledge 

versus practice. Australian Infection Control. 2003;8(1):21. 

Not an evaluation of a 

QI intervention 

From the NIH: Urinary catheter care may increase risk of infection. Jama. 

1981;246(1):30. 

Not an evaluation of a 

QI intervention 

Fryklund B, Haeggman S, Burman LG. Transmission of urinary bacterial strains 

between patients with indwelling catheters--nursing in the same room and in 

separate rooms compared. J Hosp Infect. 1997;36(2):147-53. 

Not an evaluation of a 

QI intervention 

Gastmeier P, Sohr D, Brandt C, et al. Reduction of orthopaedic wound infections in 

21 hospitals. Arch Orthop Trauma Surg. 2005;125(8):526-30. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

GDEPIH-GOSPIZ Belgian consensus strategies to control antibiotic-resistant 

bacteria in hospitals. Acta Clin Belg. 1999;54(1):15-6. 

Not an evaluation of a 

QI intervention 

Geubbels EL, Bakker HG, Houtman P, et al. Promoting quality through surveillance 

of surgical site infections: five prevention success stories. Am J Infect Control. 

2004;32(7):424-30. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Geyer S. Breathing easy. Vigilance and education can prevent VAP. Mater Manag 

Health Care. 2004;13(7):14, 6-7. 

Not an evaluation of a 

QI intervention 
C7

Gibbs H. Journal of Infection Control Nursing. Catheter toilet and urinary tract 

infections. Nurs Times. 1986;82(23):75-6. 

Not an evaluation of a 

QI intervention 

Glenwright HD, Martin MV. Infection control in dentistry. A practitioner''s guide. 

British Dental Association. Br Dent J. 1993;175(1 Suppl):8. 

Not an evaluation of a 

QI intervention 

Goetz AM, Kedzuf S, Wagener M, Muder RR. Feedback to nursing staff as an 

intervention to reduce catheter-associated urinary tract infections. American Journal 

of Infection Control 1999; 27:402. 

Other: interventions 

did not include our 

target interventions 

Goetz AM, Muder RR. The problem of methicillin-resistant Staphylococcus aureus: a 

critical appraisal of the efficacy of infection control procedures with a suggested 

approach for infection control programs. Am J Infect Control. 1992;20(2):80-4. 

Not an evaluation of a 

QI intervention 

Goode CJ, Piedalue F. Evidence-based clinical practice. J Nurs Adm. 

1999;29(6):15-21. 

Not an evaluation of a 

QI intervention 

Gorecki PJ, Schein M, Mehta V, et al. Surgeons and infectious disease specialists: 

different attitudes towards antibiotic treatment and prophylaxis in common abdominal 

surgical infections. Surg Infect (Larchmt). 2000;1(2):115-23; discussion 25-6. 

Not an evaluation of a 

QI intervention 

Gorecki W, Grochowska E, Krysta M, et al. A prospective comparison of antibiotic 

usage in pediatric surgical patients: the safety, advantage, and effectiveness of the 

Surgical Infection Society guidelines versus a common practice. J Pediatr Surg. 

2002;37(10):1430-4. 

Excluded topic 

Gould D, Chamberlain A. The use of a ward-based educational teaching package to 

enhance nurses' compliance with infection control procedures. Journal of Clinical 

Nursing 1997; 6:55. 

Other: out of scope 

Grady NPO, Alexander M, Dellinger EP, et al. Guidelines for the prevention of 

intravascular catheter-related infections. Infect Control Hosp Epidemiol. 

2002;23(12):759-69. 

Not an evaluation of a 

QI intervention 

Greene JN. Catheter-related complications of cancer therapy. Infect Dis Clin North 

Am. 1996;10(2):255-95. 

Not an evaluation of a 

QI intervention 

Hand washing, cleaning, disinfection and sterilization in health care. Can Commun 

Dis Rep. 1998;24 Suppl 8:i-xi, 1-55, i-xi, 1-7. 

Not an evaluation of a 

QI intervention 

Hanucharurnkui S, Vinya-nguag P. Effects of promoting patients' participation in selfcare on postoperative recovery and satisfaction with care. Nurs Sci Q. 1991;4(1):14-

20. 

Not an evaluation of a 

QI intervention 

Harper P. Guidelines for preventing hospital-acquired infection. Nurs Times. 

2001;97(13):34-6. 

Not an evaluation of a 

QI intervention 

Harris JR, Miller TH. Preventing nosocomial pneumonia: evidence-based practice. 

Crit Care Nurse. 2000;20(1):51-66; quiz 7-8. 

Not an evaluation of a 

QI intervention 

Heriteau FL, Alberti C, Cohen Y, et al. Nosocomial infection and multidrug-resistant 

bacteria surveillance in intensive care units: a survey in France. Infect Control Hosp 

Epidemiol. 2005;26(1):13-20. 

Not an evaluation of a 

QI intervention 

HIV and bloodborne infections in emergency medicine. American College of 

Emergency Physicians. Ann Emerg Med. 1997;29(4):571-2. 

Not an evaluation of a 

QI intervention 

Hixson S, Sole ML, King T. Nursing strategies to prevent ventilator-associated 

pneumonia. AACN Clin Issues. 1998;9(1):76-90; quiz 145-6. 

Not an evaluation of a 

QI intervention 

Hong SW, Ching TY, Fung JP, et al. The employment of ward opinion leaders for 

continuing education in the hospital. Medical Teacher. 1990;12(2):209. 

No eligible outcomes 
C8

Hopkins J, Shoemaker W, Greenfield S, et al. Treatment of surgical emergencies 

with and without an algorithm. Archives of Surgery. 1980;115(6):745. 

Excluded topic 

Hospital cuts time on ventilators, ICU LOS. Healthc Benchmarks. 1999;6(5):57-9. Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial 

antimicrobial therapy, and preventive strategies. A consensus statement, American 

Thoracic Society, November 1995. Am J Respir Crit Care Med. 1996;153(5):1711-

25. 

Not an evaluation of a 

QI intervention 

How a hospital uses its surgical site infection measure. Jt Comm Perspect. 

2001;21(10):8-9. 

Not an evaluation of a 

QI intervention 

Ibeziako PA, Ayeni O. Postoperative wound sepsis in obstetric and gynecologic 

surgery. Int Surg. 1979;64(2):67-70. 

Not an evaluation of a 

QI intervention 

Ibrahim EH, Ward S, Sherman G, et al. Experience with a clinical guideline for the 

treatment of ventilator-associated pneumonia. Crit Care Med. 2001;29(6):1109-15. 

Not an evaluation of a 

QI intervention 

ICU improvement project cuts central line infections 50%. Perform Improv Advis. 

2005;9(12):137-8, 3. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Infection control during gastrointestinal endoscopy. Guidelines for clinical application. 

Gastrointest Endosc. 1988;34(3 Suppl):37S-40S. 

Not an evaluation of a 

QI intervention 

Injection safety. Trop Doct. 2003;33(1):48-9. Not an evaluation of a 

QI intervention 

Isakow W, Kollef MH. Preventing ventilator-associated pneumonia: an evidencebased approach of modifiable risk factors. Semin Respir Crit Care Med. 

2006;27(1):5-17. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Jansen D. The impact of a clinical nurse's role on CVC infections and bacteremia: a 

two year comparative, retrospective study. Aust Nurs J 1994; 1:22-5. 

Other: no eligible 

preventive practices 

Jarvis WR. Benchmarking for prevention: the Centers for Disease Control and 

Prevention's National Nosocomial Infections Surveillance (NNIS) system experience. 

Infection. 2003;31 Suppl 2:44-8. 

Not an evaluation of a 

QI intervention 

Jenkinson H. Urinary catheter-related infection: an education programme for users. 

Br J Community Nurs. 2005;10(2):77-80. 

Not an evaluation of a 

QI intervention 

Jenks PJ, Shaw EJ. Recurrent septicaemia due to "Achromobacter group B". J 

Infect. 1997;34(2):143-5. 

Not an evaluation of a 

QI intervention 

Johnson S, Gerding DN, Olson MM, et al. Prospective, controlled study of vinyl glove 

use to interrupt Clostridium difficile nosocomial transmission. American Journal of 

Medicine. 1990;88(2):137. 

Not an evaluation of a 

QI intervention 

Jorbeck H, Sterner G, Enocksson E, et al. Staphylococcal infection in pregnancy at 

term. Scand J Infect Dis Suppl. 1990;71:86-8. 

Not an evaluation of a 

QI intervention 

Kamgang P, Tintillier M, Pochet JM, et al. Pretibial swelling revealing infected 

vascular graft. Acta Clin Belg. 2004;59(4):229-31. 

Not an evaluation of a 

QI intervention 

Kapadia F, Rodrigues C. Central venous catheter infections. Intensive Care Med. 

1996;22(7):714. 

Not an evaluation of a 

QI intervention 

Kaye J, Ashline V, Erickson D, et al. Critical care bug team: a multidisciplinary team 

approach to reducing ventilator-associated pneumonia. Am J Infect Control 2000; 

28:197-201. 

Other 
C9

Keenan SP, Heyland DK, Jacka MJ, et al. Ventilator-associated pneumonia. 

Prevention, diagnosis, and therapy. Crit Care Clin. 2002;18(1):107-25. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Keith DD, Garrett KM, Hickox G, et al. Ventilator-associated pneumonia: improved 

clinical outcomes. J Nurs Care Qual. 2004;19(4):328-33; quiz 34-5. 

Not an evaluation of a 

QI intervention 

Kelly AJ, Bailey R, Davies EG, et al. An audit of early wound infection after elective 

orthopaedic surgery. J R Coll Surg Edinb. 1996;41(2):129-31. 

Not an evaluation of a 

QI intervention 

Khanam T, Branthwaite MA, English IC, et al. The control of pulmonary sepsis in 

intensive therapy units. A study at the Brompton Hospital, London. Anaesthesia. 

1973;28(1):17-28. 

Not an evaluation of a 

QI intervention 

Khatib M, Jamaleddine G, Abdallah A, et al. Hand washing and use of gloves while 

managing patients receiving mechanical ventilation in the ICU. Chest 1999; 116:172-

5. 

Other: out of scope 

Kiernan M. Reducing the risks of device-related infection caused by staphylococci. 

Prof Nurse. 2003;18(8):441-4. 

Not an evaluation of a 

QI intervention 

Killion A. Reducing the risk of infection from indwelling urethral catheters. Nursing. 

1982;12(5):84-8. 

Not an evaluation of a 

QI intervention 

Kirk SJ, Cooper GC, Moorehead RJ, et al. Wound sepsis in 10,000 surgical patients. 

Ulster Med J. 1990;59(1):36-40. 

Not an evaluation of a 

QI intervention 

Kitson A, Harvey G, Hyndman S, et al. The Impact of a Nursing Quality Assurance 

Approach, the Dynamic Standard Setting System (DySSSy), on Nursing Practice 

and Patient Outcomes (The ODySSSy Project). National Institute for Nursing Report. 

1994; 2. 

Other: article not 

available 

Kjaeldgaard P, Cordtz T, Sejberg D, et al. The DANOP-DATA system: a low-cost 

personal computer based program for monitoring of wound infections in surgical 

ward. J Hosp Infect. 1989;13(3):273-9. 

Not an evaluation of a 

QI intervention 

Kramer B. Ventilator-associated pneumonia in critically ill patients. Ann Intern Med. 

1999;130(12):1027-8. 

Not an evaluation of a 

QI intervention 

Krasner D. The AHCPR pressure ulcer infection control recommendations revisited. 

Ostomy Wound Manage. 1999;45(1A Suppl):88S-91S; quiz 2S-3S. 

Not an evaluation of a 

QI intervention 

Krukowski ZH, Matheson NA. Ten-year computerized audit of infection after 

abdominal surgery. Br J Surg. 1988;75(9):857-61. 

Not an evaluation of a 

QI intervention 

Krzywda E. Central to vascular access: clinical practice. Nutr Clin Pract. 

1996;11(3):87-8. 

Not an evaluation of a 

QI intervention 

Kunin CM. Nosocomial urinary tract infections and the indwelling catheter: what is 

new and what is true? Chest. 2001;120(1):10-2. 

Not an evaluation of a 

QI intervention 

Lacroix J, Gauvin F. Habit and the hub. Crit Care Med. 2003;31(5):1583-4. Not an evaluation of a 

QI intervention 

Lange BJ, Weiman M, Feuer EJ, et al. Impact of changes in catheter management 

on infectious complications among children with central venous catheters. Infect 

Control Hosp Epidemiol 1997; 18:326-32. 

Other: no eligible 

preventive practices 

Langley JM, Hanakowski M, Leblanc JC. Unique epidemiology of nosocomial urinary 

tract infection in children. Am J Infect Control. 2001;29(2):94-8. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Lapchik MS, Filho AC, Pestana JO, et al. Risk factors for nosocomial urinary tract 

and postoperative wound infections in renal transplant patients: a matched-pair 

case-control study. J Urol. 1992;147(4):994-8. 

Not an evaluation of a 

QI intervention 

Laurent C. Preventing infection from indwelling catheters. Nurs Times. 

1998;94(25):60-2, 4. 

Not an evaluation of a 

QI intervention 
C10

LaVoie K, Kopnick M. Impact of dressing materials on central venous catheter 

infection rates. J Intraven Nurs. 1998;21(3):140-2. 

Not an evaluation of a 

QI intervention 

Lawson P. Zapping VAP with evidence-based practice. Nursing. 2005;35(5):66-7. Not an evaluation of a 

QI intervention 

Ledger WJ, Reite AM, Headington JT. A system for infectious disease surveillance 

on an obstetric service. Obstet Gynecol. 1971;37(5):769-78. 

Not an evaluation of a 

QI intervention 

Leon C, Alvarez-Lerma F, Ruiz-Santana S, et al. Antiseptic chamber-containing hub 

reduces central venous catheter-related infection: a prospective, randomized study. 

Crit Care Med. 2003;31(5):1318-24. 

Not an evaluation of a 

QI intervention 

Levy MM, Pronovost PJ, Dellinger RP, et al. Sepsis change bundles: converting 

guidelines into meaningful change in behavior and clinical outcome. Crit Care Med. 

2004;32(11 Suppl):S595-7. 

Not an evaluation of a 

QI intervention 

Liberati A, Pifferi RDA, Torri V, et al. Antibiotic prophylaxis to reduce respiratory tract 

infections and mortality in adults receiving intensive care. Cochrane Database Syst 

Rev. 2004(1):CD000022. 

Not an evaluation of a 

QI intervention 

Lief D. A practical guide for the prevention of catheter-associated urinary tract 

infections. Auaa J. 1985;6(1):16-7. 

Not an evaluation of a 

QI intervention 

Lindan R. Catheter care team heads off urinary infections. Hospitals. 

1972;46(10):86-94. 

Not an evaluation of a 

QI intervention 

Logghe C, Ossel CV, Hoore WD, et al. Evaluation of chlorhexidine and silversulfadiazine impregnated central venous catheters for the prevention of bloodstream 

infection in leukaemic patients: a randomized controlled trial. J Hosp Infect. 

1997;37(2):145-56. 

Not an evaluation of a 

QI intervention 

Maas A, Flament P, Pardou A, et al. Central venous catheter-related bacteraemia in 

critically ill neonates: risk factors and impact of a prevention programme. J Hosp 

Infect 1998; 40:211-24. 

Other: no eligible 

preventive practices 

Maki DG, Hennekens CH, Bennett JV. Prevention of catheter-associated urinary 

tract infection. An additional measure. Jama. 1972;221(11):1270-1. 

Not an evaluation of a 

QI intervention 

Maki DG, Stolz SM, Wheeler S, et al. Prevention of central venous catheter-related 

bloodstream infection by use of an antiseptic-impregnated catheter. A randomized, 

controlled trial. Ann Intern Med. 1997;127(4):257-66. 

Not an evaluation of a 

QI intervention 

Manso E, Sio GD, Biavasco F, et al. Vancomycin-resistant enterococci. Lancet. 

1993;342(8871):616-7. 

Not an evaluation of a 

QI intervention 

Marelich GP, Murin S, Battistella F, et al. Protocol weaning of mechanical ventilation 

in medical and surgical patients by respiratory care practitioners and nurses: effect 

on weaning time and incidence of ventilator-associated pneumonia. Chest. 

2000;118(2):459. 

Not an evaluation of a 

QI intervention 

Marena C, Lodola L, Zecca M, et al. Assessment of handwashing practices with 

chemical and microbiologic methods: preliminary results from a prospective 

crossover study. AJIC: American Journal of Infection Control. 2002;30(6):334. 

No eligible outcomes 

Mathews PJ. Ventilator-associated infections. Part II. Reducing the risks. Nursing. 

1997;27(3):50-1. 

Not an evaluation of a 

QI intervention 

Mathews PJ. Ventilator-associated infections. Reducing the risks. Part I. Nursing. 

1997;27(2):59-61. 

Not an evaluation of a 

QI intervention 

Mathias JM. Curbing CABG infection rates. OR Manager 1999; 15:36. Other: no eligible 

preventive practices 
C11

McConkey SJ, L'Ecuyer PB, Murphy DM, et al. Results of a comprehensive infection 

control program for reducing surgical-site infections in coronary artery bypass 

surgery: further data from the authors. Infect Control Hosp Epidemiol 1999; 20:791-

2. 

Duplicate publication 

McConnell SA, Gubbins PO, Anaissie EJ. Do antimicrobial-impregnated central 

venous catheters prevent catheter-related bloodstream infection? Clin Infect Dis. 

2003;37(1):65-72. 

Not an evaluation of a 

QI intervention 

McDonald H. Changing practice: modified clean technique for intermittent 

catheterization. SCI Nurs. 2001;18(1):30-3. 

No eligible outcomes 

McKinney BC. Cut your patients'' risk of nosocomial UTI. Rn. 1995;58(11):20-3; quiz 

4. 

Not an evaluation of a 

QI intervention 

Meakins JL, Wicklund B, Forse RA, et al. The surgical intensive care unit: current 

concepts in infection. Surg Clin North Am. 1980;60(1):117-32. 

Not an evaluation of a 

QI intervention 

Medical devices alert. Subject: Transmission of blood-borne pathogens via springloaded lancet devices. Can J Med Technol. 1991;53(1):51-2. Not an evaluation of a 

QI intervention 

Meduri GU, Johanson WGJ. International Consensus Conference: clinical 

investigation of ventilator-associated pneumonia. Introduction. Chest. 1992;102(5 

Suppl 1):551S-2S. 

Not an evaluation of a 

QI intervention 

Meduri GU. Ventilator-associated pneumonia in patients with respiratory failure. A 

diagnostic approach. Chest. 1990;97(5):1208-19. 

Not an evaluation of a 

QI intervention 

Meister S. Emerging risks: inappropriately prolonged mechanical ventilation. QRC 

Advis. 1993;9(6):1-3. 

Not an evaluation of a 

QI intervention 

Mermel L. Central venous catheter-related infections and their prevention: is there 

enough evidence to recommend tunneling for short-term use? Crit Care Med. 

1998;26(8):1315-6. 

Not an evaluation of a 

QI intervention 

Midgley JW, Osterhage RA. Effect of nursing instruction and length of hospitalization 

on postoperative complications in cholecystectomy patients. Nursing Research. 

1973;22(1):69. 

Excluded topic 

Miller J, Preston TD, Dann PE, et al. Charting v computers in a postoperative 

cardiothoracic ITU. Nurs Times. 1978;74(34):1423-5. 

Excluded topic 

Miller MR, Pronovost PJ, Burstin HR. Pediatric patient safety in the ambulatory 

setting. Ambul Pediatr. 2004;4(1):47-54. 

Not an evaluation of a 

QI intervention 

Miller SD, Andrassy RJ. Complications in pediatric surgical oncology. J Am Coll 

Surg. 2003;197(5):832-7. 

Not an evaluation of a 

QI intervention 

Mitchell RG. Urinary Tract Infections Caused by Salmonellae. Lancet. 

1965;14:1092-3. 

Not an evaluation of a 

QI intervention 

Mitchell RG. Urinary Tract Infections Due to Coagulase-Negative Staphylococci. J 

Clin Pathol. 1964;17:105-6. 

Not an evaluation of a 

QI intervention 

Model these best practices to prevent surgical infections. Perform Improv Advis. 

2004;8(5):49-51. 

Not an evaluation of a 

QI intervention 

Montagnac R, Schillinger F. Rifampicin-protamine protocol applied for prevention of 

central catheter sepsis in haemodialysis. Nephrol Dial Transplant. 1993;8(3):289-90. 

Not an evaluation of a 

QI intervention 

Montesinos I, Salido E, Delgado T, et al. Epidemiology of methicillin-resistant 

Staphylococcus aureus at a university hospital in the Canary Islands. Infect Control 

Hosp Epidemiol. 2003;24(9):667-72. 

Not an evaluation of a 

QI intervention 

Mooney BR, Armington LC. Infection control: how to prevent nosocomial infections. 

Rn. 1987;50(9):20-3. 

Not an evaluation of a 

QI intervention 
C12

Moretti EW, Ofstead CL, Kristy RM, et al. Impact of central venous catheter type and 

methods on catheter-related colonization and bacteraemia. J Hosp Infect. 

2005;61(2):139-45. 

Not an evaluation of a 

QI intervention 

Mulin B, Rouget C, Clement C, et al. Association of private isolation rooms with 

ventilator-associated Acinetobacter baumanii pneumonia in a surgical intensive-care 

unit. Infect Control Hosp Epidemiol. 1997;18(7):499-503. 

Not an evaluation of a 

QI intervention 

Murtough SM, Hiom SJ, Palmer M, et al. Biocide rotation in the healthcare setting: is 

there a case for policy implementation? J Hosp Infect. 2001;48(1):1-6. 

Not an evaluation of a 

QI intervention 

National Clostridium difficile Standards Group: Report to the Department of Health. J 

Hosp Infect. 2004;56 Suppl 1:1-38. 

Not an evaluation of a 

QI intervention 

Neumayer L, Mastin M, Vanderhoof L, et al. Using the Veterans Administration 

National Surgical Quality Improvement Program to improve patient outcomes. J Surg 

Res 2000; 88:58-61. 

Other: interventions 

did not include our 

target interventions 

Newell WRaJ. Assessing, treating and managing patients with sepsis. Nurs Stand. 

2005;19(50):56-64. 

Not an evaluation of a 

QI intervention 

Ng SP, Gomez JM, Lim SH, et al. Reduction of nosocomial infection in a neonatal 

intensive care unit (NICU). Singapore Med J 1998; 39:319-23. 

Other: no eligible 

preventive practices 

Ngo A, Murphy S. A theory-based intervention to improve nurses' knowledge, selfefficacy, and skills to reduce PICC occlusion. J Infus Nurs. 2005;28(3):173-81. Excluded topic 

Niederman MS, Summer ATaW. Invasive diagnostic testing is not needed routinely 

to manage suspected ventilator-associated pneumonia. Am J Respir Crit Care Med. 

1994;150(2):565-9. 

Not an evaluation of a 

QI intervention 

Noer HH, Jensen LP, Kalms SB, et al. The use of a personal computer program for 

monitoring wound infections and other complications in orthopedics. Int J Clin Monit 

Comput. 1991;8(1):13-8. 

Not an evaluation of a 

QI intervention 

Noone P, Shafi MS. Controlling infection in a district general hospital. J Clin Pathol. 

1973;26(2):140-5. 

Not an evaluation of a 

QI intervention 

Nosocomial pneumonia in intubated patients. N Engl J Med. 1988;318(22):1465-7. Not an evaluation of a 

QI intervention 

Noy D, Creedy D. Postdischarge surveillance of surgical site infections: a multimethod approach to data collection. Am J Infect Control. 2002;30(7):417-24. Not an evaluation of a 

QI intervention 

Nystrom B. Hospital infection control in Sweden. Chemotherapy. 1988;34(6):541-7. Not an evaluation of a 

QI intervention 

O'Grady NP, Gerberding JL, Weinstein RA, et al. Patient safety and the science of 

prevention: the time for implementing the Guidelines for the prevention of 

intravascular catheter-related infections is now. Crit Care Med. 2003;31(1):291-2. 

Not an evaluation of a 

QI intervention 

O'Grady NP. On the road to avoiding adverse events: educational programs pave 

the way. Crit Care Med. 2003;31(7):2077-8. 

Not an evaluation of a 

QI intervention 

O'Grady PN, Alexander M, Dellinger EP, et al. Guidelines for the prevention of 

intravascular catheter-related infections. Am J Infect Control. 2002;30(8):476-89. 

Not an evaluation of a 

QI intervention 

O'Riordan C, Adler JL, Banks HH, et al. A prospective study of wound infections on 

an orthopedic service with illustrative cases. Clin Orthop Relat Res. 1972;87:188-91. 

Not an evaluation of a 

QI intervention 

O'Riordan C, Adler JL, Banks HH, et al. Wound infections on an orthopedic service. 

A prospective study. Am J Epidemiol. 1972;95(5):442-50. 

Not an evaluation of a 

QI intervention 
C13

Osmon SB, Kollef MH. Prevention of pneumonia in the hospital setting. Clin Chest 

Med. 2005;26(1):135-42. 

Not an evaluation of a 

QI intervention 

Oyama A. Intravenous line management and prevention of catheter-related 

infections in America. J Intraven Nurs. 2000;23(3):170-5. 

Not an evaluation of a 

QI intervention 

Panhotra BR, Saxena AK, Al-Arabi AAM. The effect of a continuous educational 

program on handwashing compliance among healthcare workers in an intensive care 

unit. Br J Infection Control 2004;5(3):15 

Other: out of scope 

Parienti JJ, Cheyron Dd, Ramakers M, et al. Alcoholic povidone-iodine to prevent 

central venous catheter colonization: A randomized unit-crossover study. Crit Care 

Med. 2004;32(3):708-13. 

Not an evaluation of a 

QI intervention 

Parienti JJ, Thibon P, Heller R, et al. Hand-rubbing with an aqueous alcoholic 

solution vs traditional surgical hand-scrubbing and 30-day surgical site infection 

rates: a randomized equivalence study. Jama. 2002;288(6):722-7. 

Not an evaluation of a 

QI intervention 

Parker LJ. Urinary catheter management: minimizing the risk of infection. Br J Nurs. 

1999;8(9):563-6, 8, 70 passim. 

Not an evaluation of a 

QI intervention 

Parker MJ, Pryor GA, Myles JW. The value of a special surgical team in preventing 

complications in the treatment of hip fractures. Int Orthop. 1994;18(3):184-8. 

Excluded topic 

Parkinson R, Gandhi M, Harper J, et al. Establishing an ultrasound guided 

peripherally inserted central catheter (PICC) insertion service. Clin Radiol. 

1998;53(1):33-6. 

Not an evaluation of a 

QI intervention 

Perioperative red cell transfusion. Natl Inst Health Consens Dev Conf Consens 

Statement. 1988;7(4):1-6. 

Not an evaluation of a 

QI intervention 

Philipneri M, Al-Aly Z, Amin K, et al. Routine replacement of tunneled, cuffed, 

hemodialysis catheters eliminates paraspinal/vertebral infections in patients with 

catheter-associated bacteremia. Am J Nephrol. 2003;23(4):202-7. 

Not an evaluation of a 

QI intervention 

Pick FC, Rose M, Wang D, et al. The prevention of spread of methicillin resistant 

Staphylococcus aureus in a spinal injuries centre. Paraplegia. 1994;32(11):732-5. 

Not an evaluation of a 

QI intervention 

Pingleton SK, Fagon JY, Leeper KVJ. Patient selection for clinical investigation of 

ventilator-associated pneumonia. Criteria for evaluating diagnostic techniques. 

Chest. 1992;102(5 Suppl 1):553S-6S. 

Not an evaluation of a 

QI intervention 

Piotrowski MM, Hinshaw DB. The safety checklist program: creating a culture of 

safety in intensive care units. Jt Comm J Qual Improv. 2002;28(6):306-15. 

Not an evaluation of a 

QI intervention 

Png DJ, Ong CL, Chan S. Surgical Nutritional Team and its impact on total 

parenteral nutrition in The National University Hospital, Singapore. International 

Journal of Clinical Practice 1997; 51:350. 

Other: no 

documentation of QI 

intervention 

Pons R, Blasco C, Jimenez J, et al. Nursing protocol for manipulation of 

haemodialysis catheters. Edtna Erca J. 1996;22(4):39-42. 

Not an evaluation of a 

QI intervention 

Prescott RJ, Ruckley CV, Garraway WM, et al. Functional assessment of patients 

undergoing day-care surgery for varicose veins or hernia: results from a randomised 

controlled trial. Health Bulletin. 1979;37(2):82. 

Excluded topic 

Preventing infections associated with indwelling intravascular access devices. Can 

Commun Dis Rep. 1997;23 Suppl 8:i-iii, 1-32, i-iv, 1-16. 

Not an evaluation of a 

QI intervention 

Price CS, Hacek D, Noskin GA, et al. An outbreak of bloodstream infections in an 

outpatient hemodialysis center. Infect Control Hosp Epidemiol. 2002;23(12):725-9. 

Not an evaluation of a 

QI intervention 
C14

Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: a model 

for safety improvement. Jt Comm J Qual Saf. 2004;30(2):59-68. 

Excluded topic 

Proposed recommended practices for surgical hand scrubs. Association of Operating 

Room Nurses. Aorn J. 1994;60(2):270, 3-6, 9-80. 

Not an evaluation of a 

QI intervention 

Proposed recommended practices. Surgical scrubs. AORN Technical Practices 

Coordinating Committee. Aorn J. 1990;51(1):226-8, 30-4. 

Not an evaluation of a 

QI intervention 

Quality Patrol. Keep it clean. Hosp Health Netw. 1997;71(19):21. Not an evaluation of a 

QI intervention 

Quarrell EJ. Artificial ventilation. 3. Nursing care. Nurs Times. 1970;66(43):1360-2. Not an evaluation of a 

QI intervention 

Raad I, Darouiche R, Dupuis J, et al. Central venous catheters coated with 

minocycline and rifampin for the prevention of catheter-related colonization and 

bloodstream infections. A randomized, double-blind trial. The Texas Medical Center 

Catheter Study Group. Ann Intern Med. 1997;127(4):267-74. 

Not an evaluation of a 

QI intervention 

Raad I. Intravascular-catheter-related infections. Lancet. 1998;351(9106):893-8. Not an evaluation of a 

QI intervention 

Rackoff WR, Weiman M, Jakobowski D, et al. A randomized, controlled trial of the 

efficacy of a heparin and vancomycin solution in preventing central venous catheter 

infections in children. J Pediatr. 1995;127(1):147-51. 

Not an evaluation of a 

QI intervention 

Rahal JJ. Short-term therapy for intravascular catheter-related Staphylococcus 

aureus bacteremia. Clin Infect Dis. 2001;33(11):1946-7; author reply 9-51. 

Not an evaluation of a 

QI intervention 

Raine SJ. Quality assurance and the role of infection control: a retrospective study of 

hospital-acquired infection in a District General Hospital based on three sites, 1978-

1988. J Hosp Infect. 1991;19(1):49-61. 

Not an evaluation of a 

QI intervention 

Rakshi K, Couriel JM. Management of acute bronchiolitis. Arch Dis Child. 

1994;71(5):463-9. 

Not an evaluation of a 

QI intervention 

Rantala A, Lehtonen OP, Niinikoski J. Alcohol abuse: a risk factor for surgical wound 

infections? Am J Infect Control. 1997;25(5):381-6. 

Not an evaluation of a 

QI intervention 

Raphaely RC. Acute respiratory failure in infants and children. Pediatr Ann. 

1986;15(4):315-21. 

Not an evaluation of a 

QI intervention 

Recommended practices. Surgical attire. AORN Technical Practices Coordinating 

Committee. Aorn J. 1990;51(3):828, 30, 32 passim. 

Not an evaluation of a 

QI intervention 

Recommended practices. Surgical hand scrubs. AORN Recommended Practices 

Coordinating Committee. Aorn J. 1990;52(4):830-6. 

Not an evaluation of a 

QI intervention 

Reilly J, Noone A, Clift A, et al. A study of telephone screening and direct 

observation of surgical wound infections after discharge from hospital. J Bone Joint 

Surg Br. 2005;87(7):997-9. 

Not an evaluation of a 

QI intervention 

Reilly JS. The effect of surveillance on surgical wound infection rates. J Tissue 

Viability 1999; 9:57-60. 

Duplicate publication 

Reinarz JA. Nosocomial infections. Clin Symp. 1978;30(6):1-35. Not an evaluation of a 

QI intervention 

Rello J, Diaz E. Optimal use of antibiotics for intubation-associated pneumonia. 

Intensive Care Med. 2001;27(2):337-9. 

Not an evaluation of a 

QI intervention 

Rello J. Acinetobacter baumannii infections in the ICU: customization is the key. 

Chest. 1999;115(5):1226-9. 

Not an evaluation of a 

QI intervention 

Rello J. Impact of nosocomial infections on outcome: myths and evidence. Infect 

Control Hosp Epidemiol. 1999;20(6):392-4. 

Not an evaluation of a 

QI intervention 
C15

Reprocessing of flexible gastrointestinal endoscopes. American Society for 

Gastrointestinal Endoscopy. Gastrointest Endosc. 1996;43(5):540-5. 

Not an evaluation of a 

QI intervention 

Reynolds HY. Prevention and future control of hospital-associated infections 

commonly caused by gram-negative bacteria. Prev Med. 1974;3(4):507-14. 

Not an evaluation of a 

QI intervention 

Rigdon RO. Protocols for the prevention of intravascular device-related infections. 

Crit Care Nurs Q. 2001;24(2):39-47. 

Not an evaluation of a 

QI intervention 

Rijnders B. Diagnosis of catheter-related bacteremia in cancer patients. J Clin 

Microbiol. 2001;39(8):3022. 

Not an evaluation of a 

QI intervention 

Rijnders BJ, Wijngaerden EV, Vandecasteele SJ, et al. Treatment of long-term 

intravascular catheter-related bacteraemia with antibiotic lock: randomized, placebocontrolled trial. J Antimicrob Chemother. 2005;55(1):90-4. 

Not an evaluation of a 

QI intervention 

Rijnders BJ, Wijngaerden EV, Vandecasteele SJ, et al. Uncertainties and future 

research topics in the management of suspected catheter-related infection. Clin 

Infect Dis. 2001;33(11):1946; author reply 9-51. 

Not an evaluation of a 

QI intervention 

Rijnders BJ. Catheter-related infection can be prevented...if we take the arterial line 

seriously too! Crit Care Med. 2005;33(6):1437-9. 

Not an evaluation of a 

QI intervention 

Ringham S. The ambulant catheterised patient in hospital. Nurs Times. 

1984;80(37):suppl 11-2. 

Not an evaluation of a 

QI intervention 

Roberts FJ, Walsh A, Wing P, et al. The influence of surveillance methods on 

surgical wound infection rates in a tertiary care spinal surgery service. Spine. 

1998;23(3):366-70. 

Not an evaluation of a 

QI intervention 

Roberts RB. The anaesthetist, cross-infection and sterilization techniques--a review. 

Anaesth Intensive Care. 1973;1(5):400-6. 

Not an evaluation of a 

QI intervention 

Roe B. Catheter care: an overview. Int J Nurs Stud. 1985;22(1):45-56. Not an evaluation of a 

QI intervention 

Roggla G, Roggla M. Semirecumbent position in intensive care patients. Lancet. 

2000;355(9208):1012; author reply 3. 

Not an evaluation of a 

QI intervention 

Rosen MJ. AIDS: pulmonary complications and intensive care. Acute Care. 

1988;14-15:229-43. 

Not an evaluation of a 

QI intervention 

Rosenfeld BA, Dorman T, Breslow MJ, et al. Intensive care unit telemedicine: 

alternate paradigm for providing continuous intensivist care. Crit Care Med. 

2000;28(12):3925-31. 

Not an evaluation of a 

QI intervention 

Rosenthal VD, Guzman S, Safdar N. Reduction in nosocomial infection with 

improved hand hygiene in intensive care units of a tertiary care hospital in Argentina. 

Am J Infect Control 2005; 33:392-7. 

Duplicate publication 

Rubinson L, Diette GB. Best practices for insertion of central venous catheters in 

intensive-care units to prevent catheter-related bloodstream infections. J Lab Clin 

Med. 2004;143(1):5-13. 

Not an evaluation of a 

QI intervention 

Rumbak MJ, Cancio MR. Significant reduction in methicillin-resistant Staphylococcus 

aureus ventilator-associated pneumonia associated with the institution of a 

prevention protocol. Crit Care Med. 1995;23(7):1200-3. 

No eligible outcomes 

Rupp ME, Fitzgerald T, Marion N, et al. Effect of silver-coated urinary catheters: 

efficacy, cost-effectiveness, and antimicrobial resistance. Am J Infect Control. 

2004;32(8):445-50. 

Not an evaluation of a 

QI intervention 

Rupp ME, Lisco SJ, Lipsett PA, et al. Effect of a second-generation venous catheter 

impregnated with chlorhexidine and silver sulfadiazine on central catheter-related 

infections: a randomized, controlled trial. Ann Intern Med. 2005;143(8):570-80. 

Not an evaluation of a 

QI intervention 
C16

Ryan RM, Maduako K, White C, et al. Routine monitoring of all postoperative 

outcomes at one year: longitudinal study at the Royal National Throat, Nose and Ear 

Hospital. Bmj. 1996;313(7054):403. 

Not an evaluation of a 

QI intervention 

Sabui T, Tudehope D, Lennon I. Recurrent late onset group B streptococcal infection 

with parotitis. J Paediatr Child Health. 1999;35(2):224-5. 

Not an evaluation of a 

QI intervention 

Safdar N. Bloodstream infection: an ounce of prevention is a ton of work. Infect 

Control Hosp Epidemiol. 2005;26(6):511-4. 

Not an evaluation of a 

QI intervention 

Saint S, Savel RH, Matthay MA. Enhancing the safety of critically ill patients by 

reducing urinary and central venous catheter-related infections. Am J Respir Crit 

Care Med. 2002;165(11):1475-9. 

Not an evaluation of a 

QI intervention 

Salgado C, Giannetta E, Hayden F, et al. Preventing nosocomial influenza by 

improving the vaccine acceptance rate of clinicians. Infection Control and Hospital 

Epidemiology. 2004;25(11):923. 

Excluded topic 

Sanderson PJ. Preventing hospital acquired urinary and respiratory infection. Bmj. 

1995;310(6992):1452-3. 

Not an evaluation of a 

QI intervention 

Schmidt JM, Schimpeler SM. Obstetric and gynecologic abdominal wound infections: 

a comprehensive nurse-managed program. J Perinat Neonatal Nurs. 1990;4(3):25-

43. 

Not an evaluation of a 

QI intervention 

Schurink CA, Lucas PJ, Hoepelman IM, et al. Computer-assisted decision support 

for the diagnosis and treatment of infectious diseases in intensive care units. Lancet 

Infect Dis. 2005;5(5):305-12. 

Not an evaluation of a 

QI intervention 

Segura M, Alvarez-Lerma F, Tellado JM, et al. A clinical trial on the prevention of 

catheter-related sepsis using a new hub model. Ann Surg. 1996;223(4):363-9. 

Not an evaluation of a 

QI intervention 

Seto WH, Ching TY, Yuen KY, et al. The enhancement of infection control in-service 

education by ward opinion leaders. Am J Infect Control 1991; 19:86-91. 

Duplicate publication 

Sharek PJ, Benitz WE, Abel NJ, Freeburn MJ, Mayer ML, Bergman DA. Effect of an 

evidence-based hand washing policy on hand washing rates and false-positive 

coagulase negative staphylococcus blood and cerebrospinal fluid culture rates in a 

level III NICU. J Perinatol 2002; 22 (2):137-43 

Other: out of scope 

Sherman RA, Flynn NM, Bradford M, et al. Multilumen catheter sepsis and an 

educational program to combat it. Am J Infect Control. 1988;16(4):31A-4A. 

No eligible outcomes 

Shoji KT, Axnick K, Rytel MW. Infections and antibiotic use in a large municipal 

hospital 1970-1972: a prospective analysis of the effectiveness of a continuous 

surveillance program. Health Lab Sci. 1974;11(4):283-92. 

Not an evaluation of a 

QI intervention 

Shorr AF, Kollef MH. Ventilator-associated pneumonia: insights from recent clinical 

trials. Chest. 2005;128(5 Suppl 2):583S-91S. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Should you consider a bloodless program? Hosp Peer Rev. 1998;23(9):163-8. Not an evaluation of a 

QI intervention 

Siebert WT. Practical ways to avoid hospital acquired infections. Med Times. 

1977;105(7):(82)15d-(82)23d. 

Not an evaluation of a 

QI intervention 

Simchen E, Zucker D, Siegman IY, et al. Method for separating patient and 

procedural factors while analyzing interdepartmental differences in rates of surgical 

infections: the Israeli Study of Surgical Infection in Abdominal Operations. J Clin 

Epidemiol. 1996;49(9):1003-7. 

Not an evaluation of a 

QI intervention 
C17

Souvignet C, Frebourg G, Baril L. Identifying patients with severe hospital-acquired 

infections due to Staphylococcus aureus by using the Healthcare Cost and Utilization 

Project (HCUP): problems and pitfalls. Infect Control Hosp Epidemiol. 

2004;25(6):450-1. 

Not an evaluation of a 

QI intervention 

Srinivasan A, Karchmer T, Richards A, et al. A prospective trial of a novel, siliconebased, silver-coated foley catheter for the prevention of nosocomial urinary tract 

infections. Infect Control Hosp Epidemiol. 2006;27(1):38-43. 

Not an evaluation of a 

QI intervention 

Staph with lower vancomycin resistance in US. OR Manager. 1997;13(10):7. Not an evaluation of a 

QI intervention 

Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations. Medsurg 

Nurs. 2005;14(4):249-53. 

Not an evaluation of a 

QI intervention 

Stickler DJ. The role of antiseptics in the management of patients undergoing shortterm indwelling bladder catheterization. J Hosp Infect. 1990;16(2):89-108. Not an evaluation of a 

QI intervention 

Stiletto RJ. Bacterial colonization of the respiratory tract under artificial ventilation: is 

there proof of clinically relevant effects of the endotracheal tube orientation under 

positioning therapy? Crit Care Med. 2003;31(3):973-4. 

Not an evaluation of a 

QI intervention 

Stone J, Manasse R. Pseudoepidemic of urinary tract infections due to Trichosporon 

beigelii. Infect Control Hosp Epidemiol. 1989;10(7):312-5. 

Not an evaluation of a 

QI intervention 

Stone SP. Hand hygiene--the case for evidence-based education. J R Soc Med. 

2001;94(6):278-81. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Strandvik G, Mayall M. Safer central venous access. Anaesthesia. 2005;60(6):618-

9; author reply 9. 

Not an evaluation of a 

QI intervention 

Strieter RM, Lynch JP. Complications in the ventilated patient. Clin Chest Med. 

1988;9(1):127-39. 

Not an evaluation of a 

QI intervention 

Stronge JL. Infection of the urinary tract associated with catheters. Nurs Times. 

1976;72(11):426-7. 

Not an evaluation of a 

QI intervention 

Stucke VA, Thompson RE. Infection transfer by respiratory condensate during 

positive pressure respiration. Nurs Times. 1980;76(9):suppl 13 3-4. 

Not an evaluation of a 

QI intervention 

Study examines policy; how well is it followed? Hosp Infect Control. 1981;8(1):67. Not an evaluation of a 

QI intervention 

Sujijantararat R, Booth RZ, Davis LL. Nosocomial urinary tract infection: nursingsensitive quality indicator in a Thai hospital. J Nurs Care Qual. 2005;20(2):134-9. Not an evaluation of a 

QI intervention 

Summaries for patients. Can antibiotic-coated catheters help decrease the incidence 

of bloodstream infections in patients in the intensive care unit? Ann Intern Med. 

2005;143(8):I36. 

Not an evaluation of a 

QI intervention 

Surin VV. Effect of different surveillance methods on statistics of postoperative 

wound infections. J Hosp Infect. 1988;11(2):116-20. 

Not an evaluation of a 

QI intervention 

Surveillance cultures in neutropenia. Lancet. 1989;1(8649):1238-9. Not an evaluation of a 

QI intervention 

Suwitra K. Catheter associated fungal urinary tract infection. Acta Med Indones. 

2004;36(2):97-9. 

Not an evaluation of a 

QI intervention 

Swoboda S, Earsing K, Strauss K, et al. Electronic monitoring and voice prompts 

improve hand hygiene and decrease nosocomial infections in an intermediate care 

unit. Critical Care Medicine. 2004;32(2):358. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 

Tambyah PA. Catheter-associated urinary tract infections: diagnosis and 

prophylaxis. Int J Antimicrob Agents. 2004;24 Suppl 1:S44-8. 

Not an evaluation of a 

QI intervention 
C18

Taneja N, Rani P, Emmanuel R, et al. Nosocomial urinary tract infection due to 

Leuconostoc mesenteroides at a tertiary care centre in north India. Indian J Med 

Res. 2005;122(2):178-9. 

Not an evaluation of a 

QI intervention 

Tanowitz HB, Weiss LM, Currie BP. Rational approaches to antibiotic therapy of 

ventilator-associated pneumonias. Crit Care Med. 2001;29(6):1277-8. 

Not an evaluation of a 

QI intervention 

Tebbs SE, Moss H, Faroqui MH, et al. Central-venous-catheter related bacteraemia. 

Lancet. 1995;345(8952):800-1. 

Not an evaluation of a 

QI intervention 

The control of hospital infection with mechanical ventilation. Health Estate. 

2000;54(7):29-30. 

Not an evaluation of a 

QI intervention 

Thibon P, Coutour XL, Leroyer R, et al. Randomized multi-centre trial of the effects 

of a catheter coated with hydrogel and silver salts on the incidence of hospitalacquired urinary tract infections. J Hosp Infect. 2000;45(2):117-24. 

Not an evaluation of a 

QI intervention 

Thompson D, Holzmueller C, Hunt D, et al. A morning briefing: setting the stage for a 

clinically and operationally good day. Jt Comm J Qual Patient Saf. 2005;31(8):476-

9. 

Not an evaluation of a 

QI intervention 

Thompson DA, Lubomski L, Holzmueller C, et al. Integrating the intensive care unit 

safety reporting system with existing incident reporting systems. Jt Comm J Qual 

Patient Saf. 2005;31(10):585-93. 

Not an evaluation of a 

QI intervention 

Tobin MJ. Critical care medicine in AJRCCM 2000. Am J Respir Crit Care Med. 

2001;164(8 Pt 1):1347-61. 

Not an evaluation of a 

QI intervention 

Tobin MJ. Critical care medicine in AJRCCM 2002. Am J Respir Crit Care Med. 

2003;167(3):294-305. 

Not an evaluation of a 

QI intervention 

Todd B. Preventing bloodstream infection. Am J Nurs. 2006;106(1):29-30. Not an evaluation of a 

QI intervention 

Todd J, Bertoch D, Dolan S. Use of a large national database for comparative 

evaluation of the effect of a bronchiolitis/viral pneumonia clinical care guideline on 

patient outcome and resource utilization. Archives of Pediatrics & Adolescent 

Medicine. 2002;156(11):1086. 

Not an evaluation of a 

QI intervention 

Todd J. Evaluation of the introduction of the Groshong central venous catheter into 

the oncology/haematology department of a district general hospital. Eur J Cancer 

Care (Engl). 1997;6(3):215-21. 

Not an evaluation of a 

QI intervention 

Toldos CM, Ortiz G, Camara M, et al. Application of pulsed-field gel electrophoresis 

in an outbreak of infection due to Klebsiella oxytoca. J Med Microbiol. 

1997;46(10):889-90. 

Not an evaluation of a 

QI intervention 

Toltzis P, Blumer JL. Preventing central venous line infections by altering the 

composition of the infusate. Crit Care Med. 1999;27(9):2036-8. 

Not an evaluation of a 

QI intervention 

Tomic V, Svetina Sorli P, Trinkaus D, et al. Comprehensive strategy to prevent 

nosocomial spread of methicillin-resistant Staphylococcus aureus in a highly 

endemic setting. Archives of Internal Medicine. 2004;164(18):2038-43. 

No eligible outcomes 

Torres A, Carlet J. Ventilator-associated pneumonia. European Task Force on 

ventilator-associated pneumonia. Eur Respir J. 2001;17(5):1034-45. 

Not an evaluation of a 

QI intervention 

Torres A, Gonzalez J, Ferrer M. Evaluation of the available invasive and noninvasive techniques for diagnosing nosocomial pneumonias in mechanically 

ventilated patients. Intensive Care Med. 1991;17(8):439-48. 

Not an evaluation of a 

QI intervention 

Trick WE, Weinstein RA. Intravascular catheter use. How to tell when the medicine is 

worse than the malady. Am J Respir Crit Care Med. 2001;163(7):1515-6. 

Not an evaluation of a 

QI intervention 
C19

Tulaimat A, Mokhlesi B. Noninvasive ventilation for persistent weaning failure. Am J 

Respir Crit Care Med. 2004;169(9):1073; author reply -4. 

Not an evaluation of a 

QI intervention 

Tuteur PG. Pneumonia after coronary artery bypass grafting: a case for continued 

evaluation. Ann Thorac Surg. 1991;51(2):177-8. 

Not an evaluation of a 

QI intervention 

Universal precautions for preventing transmission of bloodborne pathogens in health 

care facilities: report of a consensus committee meeting. Cmaj. 1989;140(7):824-6. 

Not an evaluation of a 

QI intervention 

Valenti WM. AIDS: problem solving in infection control. Infection control, human 

immunodeficiency virus, and home health care: I. Infection risk to the patient. Am J 

Infect Control. 1994;22(6):371-2. 

Not an evaluation of a 

QI intervention 

Vandenbroucke-Grauls CM. Towards better prevention of pneumonia in the intensive 

care unit? Lancet. 1993;341(8850):932. 

Not an evaluation of a 

QI intervention 

Veenstra DL, Saint S, Saha S, et al. Efficacy of antiseptic-impregnated central 

venous catheters in preventing catheter-related bloodstream infection: a metaanalysis. Jama. 1999;281(3):261-7. 

Not an evaluation of a 

QI intervention 

Vovan TT, Brenner M, Chen JC. Acidified enteral feeds: is it physiologic? Crit Care 

Med. 1999;27(11):2577-8. 

Not an evaluation of a 

QI intervention 

Wagner DP, Knaus WA. Mortality in nosocomial urinary-tract infection. N Engl J 

Med. 1983;308(2):102-3. 

Not an evaluation of a 

QI intervention 

Walder B, Pittet D, Tramer MR. Prevention of bloodstream infections with central 

venous catheters treated with anti-infective agents depends on catheter type and 

insertion time: evidence from a meta-analysis. Infect Control Hosp Epidemiol. 

2002;23(12):748-56. 

Not an evaluation of a 

QI intervention 

Walter CW. Cross-infection and the anesthesiologist. Twelfth annual Baxter-Travenol 

Lecture. Anesth Analg. 1974;53(5):631-44. 

Not an evaluation of a 

QI intervention 

Warren DK, Kollef MH. Prevention of hospital infection. Microbes Infect. 

2005;7(2):268-74. 

Not an evaluation of a 

QI intervention 

Warren JW. Catheter-associated bacteriuria. Clin Geriatr Med. 1992;8(4):805-19. Not an evaluation of a 

QI intervention 

Warren JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am. 

1997;11(3):609-22. 

Not an evaluation of a 

QI intervention 

Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents. 

2001;17(4):299-303. 

Not an evaluation of a 

QI intervention 

Warren JW. Urethral catheters, condom catheters, and nosocomial urinary tract 

infections. Infect Control Hosp Epidemiol. 1996;17(4):212-4. 

Not an evaluation of a 

QI intervention 

Wenzel RP, Edmond MB. The evolving technology of venous access. N Engl J Med. 

1999;340(1):48-50. 

Not an evaluation of a 

QI intervention 

Widmer AF. Infection control and prevention strategies in the ICU. Intensive Care 

Med. 1994;20 Suppl 4:S7-11. 

Not an evaluation of a 

QI intervention 

Wilkes AR, Stevens AJ. Breathing system filters used with Entonox. Anaesthesia. 

2000;55(8):817-8. 

Not an evaluation of a 

QI intervention 

Willis J. Catheters--urinary tract infections. Nurs Times. 1995;91(35):48, 50. Not an evaluation of a 

QI intervention 

Wilson M. Catheterisation under scrutiny. Nurs Times. 1990;86(49):71-2. Not an evaluation of a 

QI intervention 

Wilson M. Control of infection in catheterisation. Community Nurse. 1996;2(2):31-2. Not an evaluation of a 

QI intervention 

Wing AJ. Infections of the urinary tract. II. Management. Br Med J. 1970;4(726):35-

8. 

Not an evaluation of a 

QI intervention 
C20

Woodrow P. Will nursing ICU patients in semi-recumbent positions reduce rates of 

nosocomial infection? Nurs Crit Care. 2000;5(4):174-8. 

Not an evaluation of a 

QI intervention 

Wu A, Pronovost P. Telling patients the truth. Health Aff (Millwood). 2003;22(3):249; 

author reply 

Not an evaluation of a 

QI intervention 

Wyatt TD, Timoney R. The effect of introducing a policy for catheter care on the 

catheter infection rate in a small hospital. J Hosp Infect. 1987;9(3):230-4. 

Not an evaluation of a 

QI intervention 

Yap FH, Gomersall CD, Fung KS, et al. Increase in methicillin-resistant 

Staphylococcus aureus acquisition rate and change in pathogen pattern associated 

with an outbreak of severe acute respiratory syndrome. Clin Infect Dis. 

2004;39(4):511-6. 

Not an evaluation of a 

QI intervention 

Yucel N, Lefering R, Maegele M, et al. Reduced colonization and infection with 

miconazole-rifampicin modified central venous catheters: a randomized controlled 

clinical trial. J Antimicrob Chemother. 2004;54(6):1109-15. 

Not an evaluation of a 

QI intervention 

Zimmerman JL. Problem-solving approach to adult respiratory distress syndrome. 

New Horiz. 1993;1(4):578-83. 

Not an evaluation of a 

QI intervention 

Zuschneid I, Schwab F, Geffers C, et al. Reducing central venous catheterassociated primary bloodstream infections in intensive care units is possible: data 

from the German nosocomial infection surveillance system. Infect Control Hosp 

Epidemiol. 2003;24(7):501-5. 

Study design did not 

meet criteria for RCT, 

CBA, ITS or SBA 
D1

Appendix D. Technical Experts and Peer Reviewers 

Technical Expert Panel

Martin Eccles, M.D., Centre for Health Services Research, University of Newcastle upon Tyne,

EPOC 

Russell Glasgow, Ph.D., Kaiser Permanente, Colorado 

Jeremy Grimshaw, M.B.Ch.B., Ph.D., University of Ottawa, Cochrane Collaboration Effective 

Practice and Organisation of Care Group (EPOC) 

Charles Homer, M.D., M.P.H., National Institute for Children’s Health Care Quality 

Harmon Jordan, Sc.D., previously with New England Medical Center Evidence-based Practice 

Center, currently at Abt Associates 

Val Lawrence, M.D., M.Sc., The University of Texas Health Science Center at San Antonio and 

South Texas Veterans Health Care System 

Andrew Oxman, M.D., M.Sc., Department of Health Services Research, Norwegian Directorate 

for Health and Social Welfare, EPOC 

James Zazzali, Ph.D., RAND 

Peer Reviewers

David Atkins, M.D., M.P.H., Chief Medical Officer, Agency for Healthcare Research and 

Quality, Center for Outcomes and Evidence 

Victoria Fraser, M.D., Professor of Medicine, Co-Director Division of Infectious Diseases, 

Washington University School of Medicine 

Stephan Harbarth, M.D., M.S., (For Dr. Didier Pittet), Hôpitaux Universitaires de Genève 

Service de Prévention et Contrôle de l’Infection 

Jukka Korpela, M.D., Ph.D., Medical Bacteriology Program Officer, Bacteriology and Mycology 

Branch, Division of Microbiology and Infectious Diseases NIAID / NIH / DHHS 

Ebbing Lautenbach, M.D., M.P.H., Assistant Professor of Medicine and Epidemiology U. of 

Pennsylvania 

Trish Perl, M.D., M.Sc., Assistant Professor of Medicine, Johns Hopkins University School of 

Medicine, Division of Infectious Diseases, Joint Appointment, Epidemiology, Johns 

Hopkins School of Public Health and Hygiene 

Peter Pronovost, M.D., Ph.D., Professor, Departments of Anesthesiology and Critical Care, 

Surgery, and Health Policy, Johns Hopkins University of Medicine 

Roger Resar, M.D., Senior Fellow, Institute for Healthcare Improvement (IHI) 

Thomas R. Russell, M.D., Executive Director, American College of Surgeons 

Sanjay Saint, M.D., M.P.H., Research Investigator, Ann Arbor VA Medical Center Director, 

VA/UM Patient Safety Enhancement Program Associate Professor of Medicine, 

University of Michigan Medical School, University of Michigan 

Margaret Toth, M.D., Chief Quality Officer, Delmarva Foundation, Ohio KePRO