BACKGROUND: Bloodstream infections resulting from intravascular catheters (catheter-BSI) in critical care increase patients' length of stay, morbidity and mortality, and the management of these infections and their complications has been estimated to cost the NHS annually £19.1-36.2M. Catheter-BSI are thought to be largely preventable using educational interventions, but guidance as to which types of intervention might be most clinically effective is lacking.
OBJECTIVE: To assess the effectiveness and cost-effectiveness of educational interventions for preventing catheter-BSI in critical care units in England.
DATA SOURCES: Sixteen electronic bibliographic databases - including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Cumulative Index to Nursing and Allied Health Literature (CINAHL), NHS Economic Evaluation Database (NHS EED), EMBASE and The Cochrane Library databases - were searched from database inception to February 2011, with searches updated in March 2012. Bibliographies of systematic reviews and related papers were screened and experts contacted to identify any additional references.
REVIEW METHODS: References were screened independently by two reviewers using a priori selection criteria. A descriptive map was created to summarise the characteristics of relevant studies. Further selection criteria developed in consultation with the project Advisory Group were used to prioritise a subset of studies relevant to NHS practice and policy for systematic review. A decision-analytic economic model was developed to investigate the cost-effectiveness of educational interventions for preventing catheter-BSI.
RESULTS: Seventy-four studies were included in the descriptive map, of which 24 were prioritised for systematic review. Studies have predominantly been conducted in the USA, using single-cohort before-and-after study designs. Diverse types of educational intervention appear effective at reducing the incidence density of catheter-BSI (risk ratios statistically significantly < 1.0), but single lectures were not effective. The economic model showed that implementing an educational intervention in critical care units in England would be cost-effective and potentially cost-saving, with incremental cost-effectiveness ratios under worst-case sensitivity analyses of < £5000/quality-adjusted life-year.
LIMITATIONS: Low-quality primary studies cannot definitively prove that the planned interventions were responsible for observed changes in catheter-BSI incidence. Poor reporting gave unclear estimates of risk of bias. Some model parameters were sourced from other locations owing to a lack of UK data.
CONCLUSIONS: Our results suggest that it would be cost-effective and may be cost-saving for the NHS to implement educational interventions in critical care units. However, more robust primary studies are needed to exclude the possible influence of secular trends on observed reductions in catheter-BSI.
STUDY REGISTRATION: The study is registered with PROSPERO as CRD42012001840.
FUNDING: The National Institute for Health Research Health Technology Assessment programme.
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| Physician |  |
| Nurse |  |
Nurse rater
These are conclusions/assumptions based on reviews of low quality studies and poor reporting. Surgeons presumably already use OR based sterile techniques but other HC staff/providers may not adhere to such rigorous standards. Although single lectures may not provide improved catheter BSI stats, the message here is that a series of classes may promote a standard of best practices amongst all involved HC staff to reduce these infections.
Nurse rater
I find this a very challenging article to make sense of. Clinically the important information would be which educational interventions are effective and which are not. This information is poorly presented and hard to interpret. The conclusions drawn become unsubstantiated, therefore.
Nurse rater
The full document is extensive and comprehensive, the summary does provide some insight into the findings, but the larger document provides more depth to reviews etc. The authors are all credible and from multi-centres, but one wonders that despite Critical Care specialist practitioners and infection prevention and control specialists, in recent years, providing a range of specialist education to prevent line associated infections, is this study a fore runner perhaps to a time when we no longer have and NHS or is it really about saving the NSH money? The authors make many comparisons but as they rightly demonstrate, there is a need for more qualitative and quantitative research in the UK to ascertain the effectiveness of educational interventions regarding not just central lines but also infection prevention and control generally.
Physician rater
Sometimes the search for answers to clinical problems spawns considerable research, but even with a consensus forming around numerous studies there may still be uncertainty about the conclusion and imprecision about the magnitude of benefit. Catheter-related bloodstream infections have been targeted as a major preventable cause of hospital morbidity. There has been a significant reduction in their incidence. Much of the credit has been given to interventions such as "bundles" and "checklists" as ways to improve the system and remove undesirable variability. There are unanswered questions as to whether the improvement is also related to larger secular changes, the Hawthorne effect, or redefinition. This paper looks specifically at educational interventions and concludes that they are likely to be useful when done properly. They also show evidence of being cost-effective. As always, more studies could refine the recommendation.
, McMaster University