The Joint Commission Journal on Quality and Patient Safety Performance Improvement
An Intensive Care Unit Quality Improvement Collaborative in Nine Department of Veterans Affairs Hospitals: Reducing VentilatorAssociated Pneumonia and Catheter-Related Bloodstream Infection Rates Robert S. Bonello, M.D.; Carol E. Fletcher, Ph.D., R.N.; William K. Becker, M.D., Ph.D.; Kay L. Clutter, R.N., Ph.D.; Shelley L. Arjes, R.R.T.; Jennifer J. Cook; Robert A. Petzel, M.D.
W
idespread substantive improvement in the quality of health care delivery and patient safety remains elusive, despite increasing public awareness and regulatory pressure. Reasons for the seemingly slow pace of improvement are complex and include our inability to adequately define and measure quality in many situations.1,2 Another factor is the complexity of organizational change and the need to develop appropriate models to educate and engage the health care workforce in improvement processes. In quality improvement collaboratives (QICs), care providers and others at the front line of care—the people who actually do the work—learn and apply team-based improvement principles and strategies in the workplace, often using the plan-do-study-act (PDSA) model for improvement.3,4 The concept of the care “bundle” was developed by the Institute for Healthcare Improvement (IHI) as a tool to facilitate the application of best practices and evidence-based care at the bedside. A bundle is “a structured way of improving the processes of care and patient outcomes: a small, straightforward set of practices—generally three to five—that, when performed collectively and reliably, have been proven to improve patient outcomes.”5 Sustained and reliable performance of the bundle tasks requires a high level of teamwork and collaboration, an important step in developing an organizational culture of patient safety and quality improvement (QI). A number of authors have reported dramatic reductions in the incidence of intensive care unit (ICU)–acquired infections, specifically ventilator-associated pneumonia (VAP) and catheter-related bloodstream infections (CRBSI), associated with a collaborative multiple-intervention strategy to improve adherence with evidence-based practices using the bundle approach.6–9 A large multiple-intervention QI study showed a sustained 66% reduction in the rate of CRBSI across 103 ICUs in the state of Michigan associated with implementation of a central line bundle.10
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Article-at-a-Glance Background: Measured adherence to evidence-based best
practice in the intensive care unit (ICU) setting, as in all of health care, remains unacceptably low. In 2005 to 2006, the VA Midwest Health Care Network used a quality improvement collaborative (QIC) model to improve adherence with ICU best practices in widely varying ICU and hospital settings in nine Department of Veterans Affairs (VA) hospitals. Methods: Interdisciplinary performance improvement teams at each of the participating sites implemented evidence-based ventilator and central line insertion bundles, interdisciplinary team rounds, and use of a daily patient ICU bedside checklist. Results: Adherence with all five elements of the ventilator bundle improved from 50% in the first three months to 82% in the final three months of the intervention. Mean ventilator-associated pneumonia (VAP) rates decreased by 41% over the same time frame. Use of a central line insertion checklist to monitor adherence with the central line bundle increased from 58% in the first three months to 74% in the final three months of the intervention. Mean catheter-related bloodstream infection (CRBSI) rates decreased by 48% over the same time frame. Following completion of the collaborative, eight of the nine sites continued to report on adherence with the ventilator and central line bundles, the practice of interdisciplinary team rounds, and the use of an ICU patient checklist. The incidence of VAP and CRBSI in these eight sites declined in the 12-month period following the collaborative’s completion, compared with the previous 12-month period. Discussion: Implementing the ventilator and central line bundles was associated with a reduction in rates of VAPs and CRBSIs.
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The Joint Commission Journal on Quality and Patient Safety The VA Midwest Health Care Network (Veterans Integrated Service Network or “VISN” 23) sought to determine if the QI collaborative methods could be extended across a highly diverse group of hospitals. Two bundles promoted by IHI and others were introduced in the VISN 23 ICU Collaborative: the ventilator bundle and the central line bundle.11–13 From January 2005 through June 2006, the VISN 23 ICU collaborative teams implemented and measured adherence with key components of both bundles. The goals were to increase adherence with specific evidence-based ICU practices and to determine whether this experience would serve as a springboard for additional and sustained QI across the network. In this article, we describe the results of this collaborative effort, including outcomes, experience with implementation of the QIC model, and postcollaborative efforts to sustain improvement.
Methods PARTICIPATING SITES VISN 23 is an integrated health care system that includes nine ICUs at eight medical centers in Minnesota, North and South Dakota, Iowa, and Nebraska. The Loma Linda, California, VA Medical Center, with three additional ICUs, also chose to join the VISN 23 Collaborative. The participating medical centers represented 12 ICUs, 95 ICU beds (range, 2–23 beds per medical center) and approximately 6,000 ICU admissions annually. Four sites are urban academic centers affiliated with university teaching programs.
CARE BUNDLES Key components of the VISN 23 ventilator bundle are: elevating the head of the bed, daily interruption of sedation, daily assessment of readiness to discontinue mechanical ventilation, and stress ulcer and deep venous thrombosis prophylaxis.14–19 Key components of the VISN 23 central line bundle are hand hygiene, chlorhexidine skin antisepsis, sterile gown and maximal barrier precautions with line insertion, avoiding the femoral site if possible, and daily review of line necessity.20–24
ORGANIZATIONAL CHANGES In addition to the evidence-based bundles, all teams were asked to implement two organizational changes that were central to the bundle implementations: interdisciplinary team rounds and the use of a bedside care checklist, as reported by Pronovost et al.25
QIC DESIGN Although this was not an IHI–sponsored collaborative, we 640
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adapted the IHI “Breakthrough” QIC design, as described in detail elsewhere.3 Interdisciplinary process improvement teams including frontline ICU care providers were assembled at each site. Collaborative goals and methods were shared with all of the teams via the collaborative charter and conference calls. Three learning sessions (face-to-face meetings) featured nationally recognized content and process experts, review of the relevant literature, and sharing by teams and experts of best practices and lessons learned. Team progress was shared during monthly conference calls and at the learning sessions. Education in the PDSA improvement methodology was provided to the participating teams during learning sessions and was repeated and emphasized during monthly conference calls. A collaborative Web site allowed teams to share protocols, reports, and tools. In a modification of the IHI QIC design, the collaborative leadership conducted site visits at each participating center. These visits included educational symposia with review of the relevant literature by collaborative leadership and presentations by the site teams to their own local leadership and colleagues, which reported on their progress and barriers to change.
MEASURES The primary endpoints of interest were four process measures for all sites combined: the rates of adherence to the ventilator bundle and central line insertion checklist (central line bundle) and the rates of adherence with the use of interdisciplinary team rounds and use of a daily patient bedside checklist. For most teams, a frontline ICU nurse was responsible for collecting data and submitting the monthly reports electronically. There was limited training on data collection methodology, and independent site audits were not done. Secondary endpoints included VAP and CRBSI rates for all sites combined. Each medical center’s infection control practitioners reported its VAP and CRBSI rates, using the Centers for Disease Control and Prevention’s National Nosocomial Infections Surveillance System (January 2005) definitions.26 These outcomes, along with the process measures, were uploaded to a central database on the collaborative Web site. Additional measures of interest included the rates of process adherence for each of the sites individually, rates of VAP and CRBSI, ICU length of stay, and ventilator length of stay.
DATA ANALYSIS For the primary process and outcome measures, frequencies were tallied at individual sites by nurses assigned to the study at each site. Because of the relatively small numbers from individ-
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The Joint Commission Journal on Quality and Patient Safety Process Measures: Percent Adherence (Nine Centers), January 2005–June 2006
Figure 1. For all sites combined, daily adherence with all five elements of the ventilator bundle improved from 50% in January through March 2005 (first three months of the intervention) to 82% in April through June of 2006 (final three months of the intervention). VISN, Veterans Integrated Service Network; ICU, intensive care unit; vent, ventilator.
ual sites, data were compiled in the aggregate by the collaborative leadership group for the purpose of reporting means and trends. Correlations, reported in the results, were implied but not tested statistically.
through June of 2006 (final three months of the study intervention). Mean CRBSI rates for all sites combined decreased from 5.2 to 2.7 events/1,000 line days during the same time frame, a 48% reduction (Table 1).
Results BUNDLE ADHERENCE AND ICU–ACQUIRED INFECTION RATES
ADDITIONAL OUTCOMES
Self-reported rates of adherence to bundle elements and the targeted organizational strategies are shown in Figure 1 (above). For all sites combined, daily adherence with all five elements of the ventilator bundle improved from 50% in January through March of 2005 (first three months of the intervention) to 82% in April through June of 2006 (final three months of the intervention). Mean VAP rates decreased from 11.7 to 6.9 events/1,000 ventilator days during the same time frame, a 41% reduction (Table 1, page 642). After a six-month period to establish uniform measures for CRBSI and the implementation of a central line insertion checklist to measure adherence with the central line bundle, use of the checklist for all sites combined increased from 58% of all central line insertions in July through September 2005 (first three months of the study intervention) to 74% in April
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Adherence with the four main process measures increased at all participating sites. Analysis of the impact of adherence to the process measures on VAP and CRBSI at individual sites was limited by small numbers of infections. There were no detectable or significant changes in mean ventilator length of stay or ICU length of stay following initiation of the collaborative compared with baseline.
IMPLEMENTATION: OPERATIONAL ISSUES There was generally good acceptance and very little pushback in regard to the clinical basis for the collaborative. Common operational challenges included lack of training and education for team-based collaboration, lack of infrastructure to support data collection and reporting for QI purposes, lack of physician interest or buy-in, and organizational “red tape.” The QIC model employs the PDSA method for teams to develop a site-specific process for implementing the targeted
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The Joint Commission Journal on Quality and Patient Safety Table 1. Process and Outcome Measures: First Versus Final Quarter of Intervention Results
First 3 Months
Ventilator Bundle Ventilator-Associated Pneumonia Rate
50%
82%
11.7 Infections/1,000 Ventilator Days
6.9 Infections/1,000 Ventilator Days
58%
71%
5.2 Infections/1,000 Central-Line Days
2.7 Infections/1,000 Central-Line Days
Use of Central Line Bundle Checklist Catheter-Related Bloodstream Infection Rate
interventions by conducting incremental “small tests of change” in their own workplace immediately on returning home from the learning sessions. Yet, the reality faced by some of our teams was that “business as usual” prevailed, and they found themselves isolated and tied up in bureaucratic channels, turf wars, departmental silos, organizational politics, conflicting “policies” (real or imagined), and time-consuming hospital committee processes. As an example, one of the ventilator bundle elements is interruption of daily sedation, facilitated by the adoption of an ICU–based sedation protocol. One site found that it needed to first obtain approval from its hospital’s pharmacy and therapeutics committee, which in turn required the participation and approval of the hospital’s anesthesiologists. In the absence of facilitated cooperation with these groups and individuals, the process stalled. Verbal support alone from senior leadership was not enough to overcome this barrier. Collaborative site visits provided a format for teams to air these issues with their own hospital leadership. Nevertheless, most sites exhibited a strong bias toward discussion and presentation of operational “successes” rather than barriers. Establishing team rounds on a consistent basis at all sites proved challenging. A number of the ICUs operated under an “open” model, with multiple staff or resident physicians and provider teams responsible for the care of the patient. Finding a consistent time for team rounds and getting physicians to attend team rounds proved challenging because of competing demands and varying or conflicting schedules. This was particularly true for surgeons who often had to be in the operating room at the time of team rounds. Sites that successfully established team rounds on a consistent basis early in the collaborative generally reported that team rounds were a high-leverage change that facilitated adaptation of the bundles. The team rounds served as a time to review implementation of the bundles, reinforced team members’ commitment to the process, and increased the visibility of the overall change effort. In some cases, families were invited to join team rounds. This proved to be an effective means of increasing the visibility and importance of team rounds with 642
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ICU staff and facility leadership. Physician participation was hindered primarily by time constraints and competing demands. Many physicians had little training or interest in team-based or system-level QI concepts. Despite this, we did have several physician champions across the system. Although we did not attempt to measure their effect, our perception is that they were important to the overall success of the collaborative. Physicians with strong affiliation to the Department of Veterans Affairs (VA) tended to be more enthusiastic participants. Nurses tended to be the most energetic and enthusiastic participants. However, there were still “turf ” issues and professional boundaries to contend with. We asked ICU nurses to complete the central line insertion checklist. At some sites, nurses undertook this responsibility with enthusiasm, whereas at others, there were objections from nursing (for example, “It’s not my job to police the physicians”). Perhaps the most significant and burdensome challenge faced by all teams involved the collection, management, and reporting of data. Although some funds were made available to offset salary costs, most of the data collection was carried out as collateral duty by frontline providers and nurse managers, creating additional work load.
POSTCOLLABORATIVE CHANGES Following completion of the collaborative, VISN 23 leadership authorized organization of a permanent critical care guidance committee to continue to oversee ICU QI efforts at the VISN level and to encourage collaboration and cooperation between sites. All the sites have continued the practice of interdisciplinary team rounds and the use of an ICU patient checklist and have continued to collect and report data on VAP and CRBSI to the VISN. Although we cannot make exact comparisons between the postcollaborative data, which includes only VISN 23 sites, and the overall collaborative results, which included the Loma Linda site, the incidence of VAP and CRBSI in the eight VISN 23 sites declined in the 12-month period following completion of the collaborative, compared
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The Joint Commission Journal on Quality and Patient Safety Biannual Catheter-Related Bloodstream Infection (CRBSI) and Ventilator-Associated Pneumonia (VAP) Rates at the Veterans Integrated Service Network (VISN) 23 Sites
Figure 2. The incidence of VAP and CRBSI in the eight VISN 23 sites declined in the 12-month period following completion of the collaborative, compared with the previous 12-month period.
with the previous 12-month period. There were 55 VAP events (9.6 events/1,000 ventilator days) and 37 CRBSI events (3.9 events/1,000 line days) in VISN 23 sites during the 12-month period from July 2005 through June 2006 compared with 42 VAP events (7.5 events/1,000 ventilator days) and 25 CRBSI events (2.8 events/1,000 line days) during the 12-month period from July 2006 through June 2007. This improvement appears to have been sustained. Figure 2 (above) shows the biannual and annual infection rates for the eight VISN 23 sites from baseline (start of the VISN 23 ICU collaborative) through the most recent period for which we have data (December 2007). Most sites are now actively engaged in extending the process initiated by the ICU collaborative into new areas, such as the development of severe sepsis bundles and rapid response systems. On the basis of the success of the ICU collaborative, VISN 23 has used it as a model for several additional collaborative projects, including one for chronic care and another for surgical site infections.
Discussion Using the QIC design and ICU care bundles developed by IHI, interdisciplinary teams of frontline care providers implemented
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a simple set of evidence-based ICU best practices in all ICUs in the VA Midwest Health Care Network (VISN 23) and one additional VA site during an 18-month time frame. Measured adherence with use of the ventilator and central line bundles increased significantly. Our results suggest that the collaborative model of QI can be successfully applied across a highly diverse group of hospitals, at least within an integrated health care system such as the VA, to significantly improve adherence with evidence-based care. The QIC was an effective though labor-intensive means to engage both leadership and frontline staff in a unified effort at QI. The collaborative effort was well received by nearly all frontline staff, as well as local and network leadership. There was excellent participation by all teams and all sites. All sites reported substantial improvements in all four of the shared primary quality process measures. The QIC design, PDSA methodology, and use of the bundles are designed to create and promote teamwork and collaboration and to incrementally build an organizational culture of patient safety and QI. This proved to be an ambitious and challenging task despite high-level support from senior leadership, general acceptance of the validity and importance of the targeted changes, and active participation of many frontline care
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The Joint Commission Journal on Quality and Patient Safety providers. Many of the collaborative teams experienced significant challenges, including competing organizational demands and externally imposed mandates; increased work load imposed on frontline staff associated with data collection; absence of data infrastructure focused on clinical QI; lack of education and training in team-based or system-level change; and significant limitations on physician participation, including time constraints and competing demands, interests, priorities, and affiliations. Change at this level seems to require that many disparate elements of the organization pull together. In our experience, departmental silos and hierarchical chains of command tend to counteract this cooperative effort, creating a “veto effect” on the part of individuals at multiple levels within the organization. Finally, in the presence of their own hospital leadership, teams tended to emphasize operational successes while minimizing controversies and barriers to implementation, thereby reducing the opportunities for learning. High-leverage strategies for implementing change that we identified in this QIC included establishment of a highly visible multidisciplinary team rounding process as a “signal” of organizational commitment to change, participation of patients’ families in certain aspects of the change processes, and recruitment of credible and respected physician champions to advocate for change. Implementation of the ventilator and central line bundles appears to be temporally associated with reductions in the respective rates of VAP and CRBSI. Comparing the first three months of the intervention to the final three months, we observed a 41% reduction in the mean rate of VAP for all sites combined. This result is similar to the 45% reduction in VAP reported by Resar et al.6 but is less than that in a number of other published reports employing similar methodologies, with reductions in VAP ranging from 54% to 100%.7–9 There are several possible explanations. Although we provided education on evidence-based ventilator circuit strategies and on aggressive oral hygiene, we did not measure adherence with these practices. It is possible that our rate of adherence with the ventilator bundle is actually less than that reported, given the absence of independent audits. It is also possible that our improvement in adherence with all elements of the ventilator bundle to 83% was less than that needed to effect a more significant reduction in VAP. Finally, our ability to measure the impact of the intervention across multiple sites may be limited by the inherent uncertainty and variability in the outcome measure itself.27–29 Evaluation of the impact of adherence with the ventilator bundle on VAP rates at individual sites was limited by small num644
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bers of infections, particularly at the smaller sites. The 48% reduction in CRBSI that we reported is similar to that reported by Render et al.30 but is less than that in other published reports employing similar methodologies.10,31 We found that although the infection control practitioners at all our collaborative sites initially reported using “the CDC definition” for CRBSI, there was nevertheless substantial variation between sites in how CRBSI was actually defined and measured. Collection of CRBSI data was thus deferred for the first six months of the collaborative to ensure common definitions and measurement practices and to establish a baseline. Our ability to compare practice and outcomes was also limited by our choice to measure use of a central line checklist as a surrogate for adherence with the central line bundle. This decision was made to limit what we felt was an already onerous data collection burden on frontline staff. Evaluation of the impact of adherence with the central line bundle on CRBSI rates at individual sites was also limited by small numbers of infections, particularly at the smaller sites. These limitations highlight some of the challenges we encountered in attempting to organize data collection and reporting around frontline work groups using the PDSA methodology. In the absence of automated mechanisms for data collection, these tasks were often assigned as collateral duty to frontline providers and first-line managers, creating a significant added work-load burden. There are significant challenges to ensuring rigor in data collection and reporting in this circumstance. The substantial challenges involved in evaluating the effectiveness of the QIC design have been well described elsewhere.32,33 Independent verification and auditing of selfreported rates of adherence to process measures and infection rates, and concurrent quantitative and qualitative measures of staff attitudes toward safety and teamwork, would have improved our understanding of the effectiveness of the interventions and of the QIC process. Future research should be directed to determine the most effective strategies for teaching these team-based improvement skills both to trainees and to the established workforce and to measure the relative merit of the QIC design to drive improvement compared with other QI methodologies.
Summary The VA Midwest Health Care Network (VISN 23) ICU QI Collaborative demonstrated that a collaborative model of QI can be applied across a wide variety of ICU settings within an integrated health care system to effect organizational changes
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The Joint Commission Journal on Quality and Patient Safety supportive of continuing quality improvement and improved adherence with evidence-based ICU best practices. Systematic implementation of the ventilator and central line bundles was temporally associated with a reduction in rates of ventilatorassociated pneumonia and catheter-related bloodstream infections. These improvements have been sustained for an 18-month period following completion of the collaborative. J The work for this study was performed at the following sites: VA Midwest Health Care Network: Minneapolis VA Medical Center, Minneapolis; Fargo VA Medical Center, Fargo, North Dakota; Central Iowa VA Medical Center, Des Moines, Iowa; Iowa City VA Medical Center, Iowa City, Iowa; Omaha VA Medical Center, Omaha; Sioux Falls VA Medical Center, Sioux Falls, South Dakota; Fort Meade VA Medical Center, Fort Meade, South Dakota; Hot Springs VA Medical Center, Hot Springs, South Dakota; and Loma Linda VA Medical Center, Loma Linda, California. Financial support for this study was provided by the VA Midwest Health Care Network as a 2005–2006 Network quality improvement strategic priority.
Robert S. Bonello, M.D., is Assistant Professor of Medicine and Director, Medical Intensive Care Unit, Pulmonary and Critical Care Section, Minneapolis VA Medical Center, Minneapolis. Carol E. Fletcher, Ph.D., R.N., is Research Health Science Specialist, Ann Arbor VA Medical Center, Ann Arbor, Michigan. William K. Becker, M.D., Ph.D., is Chief of Staff, Fargo VA Medical Center, Fargo, North Dakota. Kay L. Clutter, R.N, Ph.D., is Nurse Manager, Medical Intensive Care Unit; and Shelley L. Arjes, R.R.T., is Manager, Respiratory Care and Sleep Services, Minneapolis VA Medical Center. Jennifer J. Cook is Surgical/Specialty Care Service Line Health Systems Specialist; and Robert A. Petzel, M.D., is Director, VA Midwest Health Care Network, Minneapolis. Please address corresopondence to Robert Bonello,
[email protected].
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11. Institute for Healthcare Improvement: Implement the Ventilator Bundle. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ ImplementtheVentilatorBundle.htm (last accessed Sep. 16, 2008). 12. Institute for Healthcare Improvement: Implement the Central Line Bundle. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ ImplementtheCentralLineBundle.htm (last accessed Sep. 16, 2008). 13. Winters B., Dorman T.: Patient-safety and quality initiatives in the intensive-care unit. Curr Opin Anaesthesiol 19:140–145, Apr. 2006. 14. Drakulovic M.B., et al.: Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: A randomised trial. Lancet 354:1851–1858, Nov. 27, 1999. 15. Kress J.P., et al.: Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342:1471–1477, May 18, 2000. 16. Brook A.D., et al.: Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 27:2609–2615, Dec. 1999. 17. Ely E.W., et al.: Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 335:1864–1869, Dec. 19, 1996. 18. Cook D.J., et al.: Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med 330:377–381, Feb. 10, 1994. 19. Cook D., et al.: A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group. N Engl J Med 338:791–797, Mar. 19, 1998. 20. Raad I.I., et al.: Prevention of central venous catheter–related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol 15:231–238, Apr. 1994. 21. Merrer J., et al.: Complications of femoral and subclavian venous catheterization in critically ill patients. A randomized controlled trial. JAMA 286:700–707, Aug. 8, 2001. 22. Humar A., et al.: Prospective randomized trial of 10% povidone-iodine versus 0.5% tincture of chlorhexidine as cutaneous antisepsis for prevention of central venous catheter infection. Clin Infect Dis 31:1001–1007, Oct. 2000. 23. Chaiyakunapruk N., et al.: Chlorhexidine compared with povidoneiodine solution for vascular catheter-site care: A meta-analysis. Ann Intern Med 136:792–801, Jun. 4, 2002. 24. Berenholtz S.M., et al.: Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 32:2014–2020, Oct. 2004. 25. Pronovost P., et al.: Improving communication in the ICU using daily goals. J Crit Care 18:71–75, Jun. 2003. 26. Horan T.C., Andrus M., Dudeck M.A.: CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 36:309–332, Jun. 2008. 27. Klompas M., Platt R.: Ventilator-associated pneumonia—The wrong quality measure for benchmarking. Ann Intern Med 147:803–805, Dec. 4, 2007. 28. Bregeon F., et al.: Diagnostic accuracy of protected catheter sampling in ventilator-associated bacterial pneumonia. Eur Respir J 16:969–975, Nov. 2000. 29. Klompas M.: Does this patient have ventilator-associated pneumonia? JAMA 297:1583–1593, Apr. 11, 2007. 30. Render M.L., et al.: Evidence-based practice to reduce central line infections. Jt Comm J Qual Patient Saf 32:253–260, May 2006. 31. Eggimann P., et al.: Impact of a prevention strategy targeted at vascularaccess care on incidence of infections acquired in intensive care. Lancet 355:1864–1868, May 27, 2000. 32. Øvretveit J., et al.: Quality collaboratives: Lessons from research. Qual Saf Health Care 11:345–351, Dec. 2002. 33. Mittman B.S.: Creating the evidence base for quality improvement collaboratives. Ann Intern Med 140:897–901, Jun. 1, 2004.
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