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Antimicrobial devices are often used to prevent nosocomial infection, despite mixed evidence as to their efficacy. Using a national survey, we found that a hospital's use of an antimicrobial device to prevent one type of infection was associated with a higher likelihood that a similar device would be used to prevent a different infection.
Healthcare-associated infection (HAI) is costly and causes substantial morbidity. We sought to understand why some hospitals were engaged in HAI prevention activities while others were not. Because preliminary data indicated that hospital leadership played an important role, we sought better to understand which behaviors are exhibited by leaders who are successful at implementing HAI prevention practices in US hospitals.
We report phases 2 and 3 of a 3-phase study. In phase 2, 14 purposefully sampled US hospitals were selected from among the 72% of 700 invited hospitals whose lead infection preventionist had completed a quantitative survey on HAI prevention during phase 1. Qualitative data were collected during 38 semistructured phone interviews with key personnel at the 14 hospitals. During phase 3, we conducted 48 interviews during 6 in-person site visits to identify recurrent and unifying themes that characterize behaviors of successful leaders.
We found that successful leaders (1) cultivated a culture of clinical excellence and effectively communicated it to staff; (2) focused on overcoming barriers and dealt directly with resistant staff or process issues that impeded prevention of HAI; (3) inspired their employees; and (4) thought strategically while acting locally, which involved politicking before crucial committee votes, leveraging personal prestige to move initiatives forward, and forming partnerships across disciplines. Hospital epidemiologists and infection preventionists often played more important leadership roles in their hospital's patient safety activities than did senior executives.
Leadership plays an important role in infection prevention activities. The behaviors of successful leaders could be adopted by others who seek to prevent HAI.
To determine what practices are used by hospitals to prevent ventilator-associated pneumonia (VAP) and, through qualitative methods, to understand more fully why hospitals use certain practices and not others.
Mixed-methods, sequential explanatory study.
We mailed a survey to the lead infection control professionals at 719 US hospitals (119 Department of Veterans Affairs [VA] hospitals and 600 non-VA hospitals), to determine what practices are used to prevent VAP. We then selected 14 hospitals for an in-depth qualitative investigation, to ascertain why certain infection control practices are used and others not, interviewing 86 staff members and visiting 6 hospitals.
The survey response rate was 72%; 83% of hospitals reported using semirecumbent positioning, and only 21% reported using subglottic secretion drainage. Multivariable analyses indicated collaborative initiatives were associated with the use of semirecumbent positioning but provided little guidance regarding the use of subglottic secretion drainage. Qualitative analysis, however, revealed 3 themes: (1) collaboratives strongly influence the use of semirecumbent positioning but have little effect on the use of subglottic secretion drainage; (2) nurses play a major role in the use of semirecumbent positioning, but they are only minimally involved with the use of subglottic secretion drainage; and (3) there is considerable debate about the evidence supporting subglottic secretion drainage, despite a meta-analysis of 5 randomized trials of subglottic secretion drainage that generally supported this preventive practice, compared with only 2 published randomized trials of semirecumbent positioning, one of which concluded that it was ineffective at preventing the development of VAP.
Semirecumbent positioning is commonly used to prevent VAP, whereas subglottic secretion drainage is used far less often. We need to understand better how evidence related to prevention practices is identified, interpreted, and used to ensure that research findings are reliably translated into clinical practice.
Although urinary tract infection (UTI) is the most common hospital-acquired infection, there is little information about why hospitals use or do not use a range of available preventive practices. We thus conducted a multicenter study to understand better how US hospitals approach the prevention of hospital-acquired UTI.
This research is part of a larger study employing both quantitative and qualitative methods. The qualitative phase consisted of 38 semistructured phone interviews with key personnel at 14 purposefully sampled US hospitals and 39 in-person interviews at 5 of those 14 hospitals, to identify recurrent and unifying themes that characterize how hospitals have addressed hospital-acquired UTI.
Four recurrent themes emerged from our study data. First, although preventing hospital-acquired UTI was a low priority for most hospitals, there was substantial recognition of the value of early removal of a urinary catheter for patients. Second, those hospitals that made UTI prevention a high priority also focused on noninfectious complications and had committed advocates, or “champions,” who facilitated prevention activities. Third, hospital-specific pilot studies were important in deciding whether or not to use devices such as antimicrobial-impregnated catheters. Finally, external forces, such as public reporting, influenced UTI surveillance and infection prevention activities.
Clinicians and policy makers can use our findings to develop initiatives that, for example, use a champion to promote the removal of unnecessary urinary catheters or exploit external forces, such public reporting, to enhance patient safety.
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