Prevention of non-ventilator-associated hospital-acquired pneumonia in Switzerland: a type 2 hybrid effectiveness–implementation trial

Background: Non-ventilator-associated hospital-acquired pneumonia (nvHAP) is a frequent, but under-researched infection. We aimed to simultaneously test an nvHAP prevention intervention and a multifaceted implementation strategy. Methods: In this single-centre, type 2 hybrid effectiveness-implementation study, all patients of nine surgical and medical departments at the University Hospital Zurich, Switzerland, were included and surveyed over three study periods: baseline (14-33 months, depending on department), implementation (2 months), and intervention (3-22 months, depending on department). The five-measure nvHAP prevention bundle consisted of oral care, dysphagia screening and management, mobilisation, discontinuation of non-indicated proton-pump inhibitors, and respiratory therapy. The implementation strategy comprised department-level implementation teams who conducted and locally adapted the core strategies of education, training, and changing infrastructure. Intervention effectiveness on the primary outcome measure of nvHAP incidence rate was quantified using a generalised estimating equation method in a Poisson regression model, with hospital departments as clusters. Implementation success scores and determinants were derived longitudinally through semistructured interviews with health-care workers. This trial is registered with ClinicalTrials.gov (NCT03361085). Findings: Between Jan 1, 2017, and Feb 29, 2020, 451 nvHAP cases occurred during 361 947 patient-days. nvHAP incidence rate was 1·42 (95% CI 1·27-1·58) per 1000 patient-days in the baseline period and 0·90 (95% CI 0·73-1·10) cases per 1000 patient-days in the intervention period. The intervention-to-baseline nvHAP incidence rate ratio, adjusted for department and seasonality, was 0·69 (95% CI 0·52-0·91; p=0·0084). Implementation success scores correlated with lower nvHAP rate ratios (Pearson correlation -0·71, p=0·034). Determinants of implementation success were positive core business alignment, high perceived nvHAP risk, architectural characteristics promoting physical proximity of health-care staff, and favourable key individual traits. Interpretation: The prevention bundle led to a reduction of nvHAP. Knowledge of the determinants of implementation success might help in upscaling nvHAP prevention

User-centred participatory design of visual cues for isolation precautions

Background Isolation precautions are intended to prevent transmission of infectious agents, yet healthcare provider (HCP) adherence remains suboptimal. This may be due to ambiguity regarding the required precautions or to cognitive overload of HCPs. In response to the challenge of changing HCP behaviour, increasing attention should be paid to the role of engineering controls and facility design that incorporate human factors elements. In the current study, we aimed to develop an isolation precaution signage system that provides visual cues, serves as a cognitive aid at the point of care, and removes ambiguity regarding which precautions are necessary (e.g. masks, gowns, gloves, single rooms) when caring for isolated patients. Methods We employed a user-centred, participatory design approach in which HCPs were actively involved in generating an isolation precaution signage system based on human factors design principles. HCPs were purposefully sampled for each design phase to include a representative sample of potential system users. We conducted front-end analysis through interviews and observations to identify challenges related to the existing signage and to establish design requirements for new signage. This was followed by the creation of user personas, design thinking workshops, and prototyping, which then underwent iterative cycles of evaluation. Graphical symbols were developed and tested for comprehensibility. Results Front-end analysis revealed several barriers to use of the current signage system such as unclear target audience, low signal-to-noise ratio, and ambiguity regarding the applicable precautions. A comprehensive list of design requirements was generated. The project ultimately resulted in a collection of validated, comprehensible symbols and signs for contact, droplet, and airborne isolation, as well as the identification of several systems-level solutions for work re-organisation to improve compliance with isolation precautions. Conclusions The introduction of visual cues in the form of signage offers a promising opportunity to make guidelines available directly at the frontline. Anecdotal evidence based on observations and interviews with HCP have shown that the current solution is superior to previous isolation signage. User-centred participatory design was a useful approach that holds potential for further improving design in healthcare settings

User-centred participatory design of visual cues for isolation precautions

Background Isolation precautions are intended to prevent transmission of infectious agents, yet healthcare provider (HCP) adherence remains suboptimal. This may be due to ambiguity regarding the required precautions or to cognitive overload of HCPs. In response to the challenge of changing HCP behaviour, increasing attention should be paid to the role of engineering controls and facility design that incorporate human factors elements. In the current study, we aimed to develop an isolation precaution signage system that provides visual cues, serves as a cognitive aid at the point of care, and removes ambiguity regarding which precautions are necessary (e.g. masks, gowns, gloves, single rooms) when caring for isolated patients. Methods We employed a user-centred, participatory design approach in which HCPs were actively involved in generating an isolation precaution signage system based on human factors design principles. HCPs were purposefully sampled for each design phase to include a representative sample of potential system users. We conducted front-end analysis through interviews and observations to identify challenges related to the existing signage and to establish design requirements for new signage. This was followed by the creation of user personas, design thinking workshops, and prototyping, which then underwent iterative cycles of evaluation. Graphical symbols were developed and tested for comprehensibility. Results Front-end analysis revealed several barriers to use of the current signage system such as unclear target audience, low signal-to-noise ratio, and ambiguity regarding the applicable precautions. A comprehensive list of design requirements was generated. The project ultimately resulted in a collection of validated, comprehensible symbols and signs for contact, droplet, and airborne isolation, as well as the identification of several systems-level solutions for work re-organisation to improve compliance with isolation precautions. Conclusions The introduction of visual cues in the form of signage offers a promising opportunity to make guidelines available directly at the frontline. Anecdotal evidence based on observations and interviews with HCP have shown that the current solution is superior to previous isolation signage. User-centred participatory design was a useful approach that holds potential for further improving design in healthcare settings

Preventing ventilator-associated pneumonia ‒ a mixed-method study to find behavioral leverage for better protocol adherence

OBJECTIVE Preventing ventilator-associated pneumonia (VAP) is an important goal for intensive care units (ICUs). We aimed to identify the optimal behavior leverage to improve VAP prevention protocol adherence. DESIGN Mixed-method study using adherence measurements to assess 4 VAP prevention measures and qualitative analysis of semi-structured focus group interviews with frontline healthcare practitioners (HCPs). SETTING The 6 ICUs in the 900-bed University Hospital Zurich in Zurich, Switzerland.Patients and participantsAdherence to VAP prevention measures were assessed in patients with a device for invasive ventilation (ie, endotracheal tube, tracheostomy tube). Participants in focus group interviews included a convenience samples of ICU nurses and physicians. RESULTS Between February 2015 and July 2017, we measured adherence to 4 protocols: bed elevation showed adherence at 27% (95% confidence intervals [CI], 23%-31%); oral care at 41% (95% CI, 36%-45%); sedation interruption at 81% (95% CI, 74%-85%); and subglottic suctioning at 88% (95% CI, 83%-92%). Interviews were analyzed first inductively according a grounded theory approach then deductively against the behavior change wheel (BCW) framework. Main behavioral facilitators belonged to the BCW component 'reflective motivation' (ie, perceived seriousness of VAP and self-efficacy to prevent VAP). The main barriers belonged to 'physical capability' (ie, lack of equipment and staffing and side-effects of prevention measures). Furthermore, 2 primarily technical approaches (ie, 'restructuring environment' and 'enabling HCP') emerged as means to overcome these barriers. CONCLUSIONS Our findings suggest that technical, rather than education-based, solutions should be promoted to improve VAP prevention. This theory-informed mixed-method approach is an effective means of guiding infection prevention efforts

Effectiveness of an edutainment video teaching standard precautions - a randomized controlled evaluation study

Background Standard precautions are essential to prevent pathogen transmission and nosocomial infections. We assessed learning effect (primary outcome) and satisfaction (secondary outcome) of watching a 5-min humorous "edutainment (=education and entertainment) video" on Standard Precautions compared to reading a written standard operating procedure (SOP) or receiving no intervention. Methods This randomized controlled trial was executed at the University Hospital Zurich, Switzerland, a tertiary care centre with a state-of-the-art infection prevention programme. Healthcare providers (HCPs) of different medical departments were 1:1:1 randomized to watching the edutainment video (video group), reading the SOP (SOP group), or no study-specific intervention (no-intervention group). Online questionnaires included a knowledge assessment about Standard Precautions at time point (TP) 1 immediately after intervention, TP2 after 1 month, and TP3 after 3 months. Information about HCPs' satisfaction with the learning method was collected. Variables were assessed within and between groups using the appropriate non-parametric tests. Predictors for knowledge of Standard Precautions were assessed by uni- and multivariable linear regression. Results Overall, 363 predominantly female (78.2%) HCPs were included. At TP 1 and TP3, the video group scored better on the knowledge assessment against both the SOP and the no-intervention group (TP1  < .001 and 0.001, TP3  = 0.036 and 0.048). In the multivariable analysis, being member of the video group was an independent predictor for better knowledge scores. The video was rated higher than the SOP regarding satisfaction with learning experience, and video group participants more frequently indicated they would recommend their learning method to colleagues. Conclusions Watching an edutainment video proved to be more effective to improve knowledge about Standard Precautions compared to reading an SOP or no intervention. Satisfaction with the learning method was superior in the video group, suggesting higher potential for future uptake

Implementation and evaluation of a care bundle for prevention of non-ventilator-associated hospital-acquired pneumonia (nvHAP) - a mixed-methods study protocol for a hybrid type 2 effectiveness-implementation trial

BACKGROUND: Hospital acquired pneumonia (HAP) is divided in two distinct groups, ventilator-associated pneumonia (VAP) and non-ventilator-associated HAP (nvHAP). Although nvHAP occurs more frequently than VAP and results in similar mortality and costs, prevention guidelines and prevention focus almost exclusively on VAP. Scientific evidence about nvHAP prevention and its implementation is scarce. Therefore, we designed a mixed-methods hybrid type 2 effectiveness-implementation study to investigate both the effectiveness and implementation of a newly developed nvHAP prevention bundle. METHODS: This single-centre project at the 950-bed University Hospital Zurich (UHZ) will engage the wards of nine departments with substantial nvHAP rates. The nvHAP bundle consists of five primary prevention measures: 1) oral care, 2) prevention of dysphagia-related aspiration, 3) mobilization, 4) stopping unnecessary proton pump inhibitors, and, 5) respiratory therapy. Implementation includes the engagement of department-level implementation teams, who sustain the 'core' intervention components of education, training, and environmental restructuring and tailor the implementation strategy to local needs. Both effectiveness and implementation outcomes will be assessed using mixed-methods. As a primary outcome, nvHAP incidence rates will be analysed by Poisson regression models to compare incidence rates before, during, and after the implementation phases (on the hospital and department level). Additionally, the association between process indicators and nvHAP incidence rates will be analysed using longitudinal Poisson regression models. A longitudinal, qualitative study and formative evaluation based on interviews, focus groups, and observations identifies supporting or hindering factors for implementation success in participating departments dynamically over time. This accumulating implementation experience will be constantly fed back to the implementation teams and thus, represents an active implementation element. DISCUSSION: This comprehensive hybrid mixed-methods study is designed to both, measure the effectiveness of a new nvHAP prevention bundle and multifaceted implementation strategy, while also providing insights into how and why it worked or failed. The results of this study may contribute substantially to advancing knowledge and patient safety in the area of a rediscovered healthcare-associated infection - nvHAP. TRIAL REGISTRATION: ClinicalTrials.gov : NCT03361085 . Registered December 2017

Prevention of non-ventilator-associated hospital-acquired pneumonia in Switzerland: a type 2 hybrid effectiveness-implementation trial.

BACKGROUND Non-ventilator-associated hospital-acquired pneumonia (nvHAP) is a frequent, but under-researched infection. We aimed to simultaneously test an nvHAP prevention intervention and a multifaceted implementation strategy. METHODS In this single-centre, type 2 hybrid effectiveness-implementation study, all patients of nine surgical and medical departments at the University Hospital Zurich, Switzerland, were included and surveyed over three study periods: baseline (14-33 months, depending on department), implementation (2 months), and intervention (3-22 months, depending on department). The five-measure nvHAP prevention bundle consisted of oral care, dysphagia screening and management, mobilisation, discontinuation of non-indicated proton-pump inhibitors, and respiratory therapy. The implementation strategy comprised department-level implementation teams who conducted and locally adapted the core strategies of education, training, and changing infrastructure. Intervention effectiveness on the primary outcome measure of nvHAP incidence rate was quantified using a generalised estimating equation method in a Poisson regression model, with hospital departments as clusters. Implementation success scores and determinants were derived longitudinally through semistructured interviews with health-care workers. This trial is registered with ClinicalTrials.gov (NCT03361085). FINDINGS Between Jan 1, 2017, and Feb 29, 2020, 451 nvHAP cases occurred during 361 947 patient-days. nvHAP incidence rate was 1·42 (95% CI 1·27-1·58) per 1000 patient-days in the baseline period and 0·90 (95% CI 0·73-1·10) cases per 1000 patient-days in the intervention period. The intervention-to-baseline nvHAP incidence rate ratio, adjusted for department and seasonality, was 0·69 (95% CI 0·52-0·91; p=0·0084). Implementation success scores correlated with lower nvHAP rate ratios (Pearson correlation -0·71, p=0·034). Determinants of implementation success were positive core business alignment, high perceived nvHAP risk, architectural characteristics promoting physical proximity of health-care staff, and favourable key individual traits. INTERPRETATION The prevention bundle led to a reduction of nvHAP. Knowledge of the determinants of implementation success might help in upscaling nvHAP prevention. FUNDING Swiss Federal Office of Public Health

An intensive care unit outbreak with multidrug-resistant Pseudomonas aeruginosa - spot on sinks.

BACKGROUND Pseudomonas aeruginosa and other Gram-negative bacteria have the ability to persist in moist environments in healthcare settings, but their spread from these areas can result in outbreaks of healthcare-associated infections. METHODS We report the investigation and containment of a multidrug-resistant P. aeruginosa outbreak in 3 intensive care units of a Swiss university hospital. A total of 255 patients and 276 environmental samples were screened for the multidrug-resistant P. aeruginosa outbreak strain. We describe the environmental sampling and molecular characterization of patient and environmental strains, control strategies implemented, including waterless patient care. RESULTS Between March and November 2019, the outbreak affected 29 patients. Environmental sampling detected the outbreak strain in nine samples of sink siphons of three different intensive care units sharing an identical water sewage system and on one gastroscope. Three weeks after sink siphon replacement, the outbreak strain grew again in siphon-derived samples and newly-affected patients were identified. The outbreak ceased after removal of all sinks in the proximity of patients and in medication preparation areas and minimization of tap water use. Multilocus sequence typing indicated clonality (sequence type 316) in 28/29 patient isolates and all 10 environmental samples. CONCLUSIONS Sink removal combined with the introduction of waterless patient care terminated the multidrug-resistant P. aeruginosa outbreak. Sinks in intensive care units might pose a risk for point source outbreaks with P. aeruginosa and other bacteria persisting in moist environments