Improving implementation of infection control guidelines to reduce nosocomial infection rates: pioneering the report card

Journal of Hospital Infection 81 (2012) 169e176 Available online at www.sciencedirect.com

Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin

Improving implementation of infection control guidelines to reduce nosocomial infection rates: pioneering the report card A.M. Yinnon a, b, *, y, Y. Wiener-Well a, y, Z. Jerassy a, M. Dor c, R. Freund c, B. Mazouz a, T. Lupyan d, S. Shapira e, D. Attias f, M.V. Assous f, P. Kopuit a, C. Block d, D. Raveh a, Y. Freier-Dror g, A.E. Moses d, S. Benenson d a

Infectious Disease Unit, Shaare Zedek Medical Center, associated with the Hebrew UniversityeHadassah Medical School, Jerusalem, Israel b Division of Internal Medicine, Shaare Zedek Medical Center, associated with the Hebrew UniversityeHadassah Medical School, Jerusalem, Israel c Israeli Ministry of Health, Jerusalem, Israel d Department of Clinical Microbiology and Infectious Diseases, Hebrew UniversityeHadassah Medical Center, Jerusalem, Israel e Department of Surgery, Hebrew UniversityeHadassah Mount Scopus Medical Center, Jerusalem, Israel f Clinical Microbiology Laboratory, Shaare Zedek Medical Center, associated with the Hebrew UniversityeHadassah Medical School, Jerusalem, Israel g Mashav Applied Research, Jerusalem, Israel

A R T I C L E

I N F O

Article history: Received 1 August 2011 Accepted 10 April 2012 Available online 23 May 2012 Keywords: Checklist Infection control Nosocomial infections

S U M M A R Y

Background: Two detailed checklists were developed, based on published infection control guidelines, for daily use by infection control practitioners in departments and operating rooms. Aim: To assess the impact of the checklists on nosocomial infection rates in three hospitals over the course of one year. Methods: The checklists included 20 subheadings (150 items). Project nurses conducted rounds in the study (but not control) departments; during each round, the nurses selected 15e20 items for observation, marked the checklists according to appropriateness of observed behaviour and provided on-the-spot corrective education. Rates of adherence to the checklist, antibiotic use, number of obtained and positive cultures, and positive staff hand and patient environment cultures were reported monthly as a report card to relevant personnel and administrators. The rate of nosocomial infections was determined in the first and last months. Results: The baseline nosocomial infection rate was similar in the study and control departments: 37/345 (11%) and 26/270 (10%) respectively. In the last month, the rate in the study department decreased to 16/383 (4%) (P < 0.01); in the control it decreased insignificantly to 21/248 (8%) (not significant). No significant trends were detected in the number of obtained cultures, positive cultures, or antibiotic use. Adherence to guidelines

* Corresponding author. Address: Division of Internal Medicine, Shaare Zedek Medical Center, P.O. Box 3235, Jerusalem 91031, Israel. Tel.: þ972 02 6555076; fax: þ972 02 6666840. E-mail address: [email protected] (A.M. Yinnon). y Equal contributors. 0195-6701/$ e see front matter Ó 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2012.04.011

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A.M. Yinnon et al. / Journal of Hospital Infection 81 (2012) 169e176 ranged from 75% to 94% between the hospitals (P < 0.001): the overall rate increased from 80% to 91% (P < 0.01). Conclusions: The use of checklists during the conduct of infection control rounds, combined with monthly reports, was associated with a significant decrease in nosocomial infections in study departments. Ó 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Introduction Haley et al.’s pivotal study in the 1970s quantified the rate of nosocomial infections at that time as 5%.1 Their study demonstrated that dedicated infection control personnel, developing and implementing infection control guidelines, could reduce the nosocomial infection rate by one-third. More recent data, including local data, indicate that the nosocomial infection rates in most modern medical centres have surpassed 10% and may be closer to 15%.2,3 These increases are undoubtedly due to the fact that a significantly higher proportion of patients currently hospitalized, as compared to that in the 1970s, are elderly, immunocompromised and/or are undergoing procedures not available in the past.4 However, rather than accepting these facts as inevitable, the medical profession needs to increase education and implementation of evidencebased infection control methods. Unfortunately, it has proven very difficult to change human behaviour, including that of medical personnel, even when patients’ welfare or survival is at stake. Many studies have demonstrated improved adherence to certain guidelines with improved outcomes; however, as soon as the intervention was discontinued, modified behaviour quickly reverted and the obtained benefits evaporated. Healthcare professionals may learn a valuable lesson from the security measures introduced and carefully observed by the airline industry, including mandatory attendance of re-education workshops, signed checklists and double checking. The purpose of the current project was to develop a detailed checklist, based on standard evidence-based infection control guidelines, to introduce it for daily use by infection control practitioners (but leaving considerable room for their individual judgement regarding the frequency with which various items are examined), and to assess its impact on departmental rates of nosocomial infections. Application of the checklist was accompanied by real-time verbal feedback to clinical staff and publication of monthly report cards, comparing departments with each other and with themselves over time.

Methods We pioneered a comprehensive approach, consisting of the following components:

disinfection of environment/surfaces, implementation of standard precautions, etc. The checklists were organized to facilitate yes/no answers. Before initiation of the study the checklists were modified according to feedback from the participating infection control nurses and physicians. The checklists were continually reviewed and changed according to publication of new and/or revised infection control guidelines and development of local infection control issues. The checklists were distributed and explained in detail to all participating infection control personnel, as well as participating department chairmen, physicians and nurses. In our hospital, infectious disease guidelines have been distributed to all physicians and nurses as a pocket booklet and appear electronically and are updated on the intranet.18

Project nurses In each of the three participating hospitals a half-time project nurse (i.e. working for four hours per day) conducted rounds in each participating study department, but not in matched control departments. These project nurses had at least five years’ experience and were required to make daily observations of a randomly selected set of 15e20 parameters from the described checklists in each of the study departments; all items had to be covered each month. While observing the staff, the project nurse was required to give oral feedback to the staff and the checklists were marked according to the observed items. The detailed results of the daily reports of each department were entered into an Excel spreadsheet.

Monthly reports These were sent to the directors of participating departments. These reports also showed anonymously the results of other participating departments, in order to create a competitive environment. In addition, the accumulative results of the monthly reports appeared as figures to indicate improvement, steady state, or deterioration over time. Copies of the monthly reports were sent to the respective hospitals’ directors, heads of nursing administration and heads of infectious disease units. Ad hoc meetings were held with the staff of each participating study department in order to discuss the detected gaps in adherence with specific infection control guidelines. Reeducation lectures were scheduled as required.

Checklists Participating hospitals and departments Two checklists were developed from published infection control guidelines, one for inpatient departments, the other for operating rooms.5e17 The checklists were organized along 20 clinical subheadings for a total of 140 entries for departments and 170 for operating rooms, including: hand hygiene, sterile insertion of central venous catheters, preparation of patients prior to operation, behaviour in the operating rooms,

The project involved three hospitals: Shaare Zedek Medical Center, Hadassah Medical Center on Mount Scopus and Hadassah Medical Center at Ein Carem, all three in Jerusalem, Israel. In each of the first two hospitals one surgical department participated; in the latter, one medical department. For each study department a similar control department was chosen: in

A.M. Yinnon et al. / Journal of Hospital Infection 81 (2012) 169e176 all, six departments were involved in these three hospitals: three study and three control departments. In the control departments, the study nurse did not perform observations and no report cards were filled. Each participating hospital decided which departments to enrol; this decision was based on locally observed infection control problems as well as expected levels of cooperation. In one hospital, two departments of general surgery with similar case mix were enrolled; it subsequently appeared that the baseline nosocomial infection rates of these departments were low. Nonetheless, these departments’ data were included according to the intention-to-treat protocol. In the other hospital, the departments of cardiothoracic surgery and orthopaedic surgery were enrolled. These departments were selected because of their relatively high baseline infection rates. Despite the dissimilarity of these departments, one served as study department and the other as simultaneous control, while according to the study each department also served as its own control. Each hospital was required to submit monthly reports regarding sex and age of admitted patients for each department, number of admitted patients, duration of admission and death rates for both study and control departments. The latter three markers served as indicators of the severity of the patients’ case mix.

Surrogate markers The rates of adherence with guidelines were correlated with the following surrogate markers and indicators of nosocomial infections, which were also collected for the control departments. First, monthly reports on use of 10 frequently used antimicrobial agents and their total, expressed in (i) defined daily doses (DDD, the internationally accepted method of describing and comparing antimicrobial use) per 1000 hospitalizations, and (ii) defined daily doses per 1000 admission-days.3,19 These antimicrobial agents included cefamezine, cefuroxime, ceftriaxone, ceftazidime, amoxicillineclavulanate, piperacillinetazobactam, gentamicin, amikacin, meropenem and vancomycin. Second, monthly reports of the microbiology department, providing data on each department’s clinical isolates including the total number of Enterobacteriaceae, and the percentage of these producing extended-spectrum beta-lactamase (ESBL); the total number of pseudomonas and acinetobacter isolates, and the percentage of each that were carbapenem resistant; the total number of Staphylococcus aureus and the proportion that were meticillin resistant, vancomycin-resistant Enterococcus faecium (VRE), Clostridium difficile-positive stool samples, tested with a commercial enzyme-linked immunosorbent assay. Each participating hospital was requested to provide these data each month, together with the breakdown by culture specimen (blood, sputum, urine, etc.) and number of specimens submitted to the laboratory in each category. Third, active surveillance was conducted in three studies: (i) surprise hand cultures using the sterile bag with broth method. This was done twice for each department during the study period, testing a representative sample of personnel during their day shift; (ii) environmental cultures from the patients’ immediate environment, e.g. bed, personal table/ cupboard, ventilator; again this was repeated twice for each department during the study period; (iii) department-wide surveillance was conducted for one month at the beginning and end of the one-year study to determine the prevalence of

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the five most prevalent nosocomial infections e urinary tract infection, pneumonia, surgical site infection, bacteraemia, and C. difficile colitis e using standard criteria.20 Surgical site infections were monitored in surgical departments only. Standard case definitions for nosocomial infections were employed throughout this study.20 These were extensively reviewed with the study nurses.

Study protocol The study lasted 11 months, of which the first and last months served to determine the rates of nosocomial infections in the study and control departments. During the first and last months, baseline hand and environmental cultures were collected in both study and control departments. During the intervening nine months, the project nurse conducted rounds, at least three times each week, in the study departments only, using the checklist as previously described, providing feedback in real time, and submitting monthly reports to study departments.

Microbiology Hand cultures were processed with the hand-rinse method and new ‘zip-lock’ bags (25  20 cm), one bag for each staff member sampled. These commercial bags have minimal contamination and do not carry the specified target organisms, as confirmed by culture of a sample of bags. For environmental cultures standard methods were employed. Selective agar plates were used for detection of S. aureus, enterococci, Enterobacteriaceae, Pseudomonas aeruginosa and Acinetobacter baumannii.

Statistical methods Data were entered into an Excel spreadsheet (Microsoft, Redmond, WA, USA) and underwent c2-analysis or Fisher’s exact test, where appropriate. Continuous variables were compared by two-tailed Student’s t-test. P < 0.05 was considered statistically significant. Logistic regression analysis was done using SPSS (Chicago, IL, USA). Trend analysis was employed to determine trends with statistical significance for the three described surrogate markers.21

Results The baseline nosocomial infection rate was similar in the study and control departments: 37/345 (11%) patients developed a nosocomial infection in the first month of the study, as compared to 26/270 (10%) patients in the control departments. The difference was not statistically significant. By the eleventh month, the nosocomial infection rate in the study departments had decreased significantly [16/383 patients (4%); P < 0.01], whereas in the control departments it had decreased nonsignificantly [21/248 patients (8%)]. The difference in nosocomial infection rate between the study and control departments in the final month was significant (P < 0.05). No significant trends were detected in the number of cultures obtained and percentages of positive cultures. Table I shows the number of isolated multidrug-resistant Gramnegative pathogens isolated from clinical cultures throughout

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Table I Selected Gram-negative pathogens isolated from clinical samples during the one-year study period Isolated target organisms ESBL-producing Enterobacteriaceae/all Enterobacteriaceae Carbapenem-resistant pseudomonas/all pseudomonas Carbapenem-resistant acinetobacter/all acinetobacter

Study departments

Control departments

P

85/378 (22%) 11/98 (11%) 12/22 (55%)

100/395 (25%) 19/86 (22%) 23/31 (74%)

NS <0.05 NS

ESBL, extended spectrum b-lactamase.

the study: no significant differences were detected, except for the number of carbapenem-resistant pseudomonas isolates, which was considerably lower in the study departments (11/98, 11%) than in the control departments (19/86, 22%). Antibiotic use appeared to be stable, and decreased towards the close of the study in the study departments, whereas in the control departments an increase in use was noted (data not shown). However, these trends were without statistical significance. Table II records the results of cultures of staff hands and the patients’ environment. At baseline, study and control departments had similar results, although study departments had higher rates of isolation of S. aureus (P < 0.05) and Enterobacteriaceae (P < 0.01) and a lower rate of isolation of acinetobacter (P < 0.01). In the study departments, there was

a significant decrease in isolation of Enterobacteriaceae (P < 0.001) between the first and last months of the study, although a less significant increase in carriage of S. aureus and acinetobacter was noted (P < 0.05). Isolation of VRE decreased in both study and control departments. Tables III and IV record adherence to infection control guidelines in the departments and operating rooms, respectively. Overall adherence ranged from 75% to 94% between the hospitals (P < 0.001). The lowest compliance with infection prevention and control guidelines among staff was observed for hand hygiene (mean  SD: 62  14%), protective clothing and equipment (71  16%) and isolation procedures (79  19%). In the operating rooms, lowest adherence was for aseptic behaviour of anaesthetists and their assistants (71  12%) and

Table II Isolated pathogens and nosocomial infections Variables

Cultures of staff hands and patients’ environment,a n (positive cultures)/N (all obtained samples) (%) S. aureus MRSA VRE Enterobacteriaceae Pseudomonas Acinetobacter No. of nosocomial infections (n)/enrolled patients with nosocomial infection (N) Surgical site Sepsis Pneumonia Urinary tract C. difficile colitis Allb

Study department, 1st month

7/90 1/90 3/90 28/90 8/90 3/90

(8) (1) (3) (31) (9) (3)

P1

<0.05 NS NS <0.001 NS <0.05

N ¼ 345 (%)

14 2 4 20 1 41

(4) (1) (1) (6) (0) (12)

Study Control department, department, 11th month 1st month

17/90 (19) 3/90 (3) 0/90 9/90 (10) 3/90 (3) 12/90 (13) N ¼ 383

<0.05 NS NS <0.01 NS <0.001

6 (2) 5 (1) 2 (1) 7 (2) 2 (1) 22 (6)

0/90 0/90 7/90 23/90 6/90 14/90

(8) (26) (7) (16)

P2

<0.05 NS <0.05 NS NS NS

N ¼ 270

9 7 11 11 2 40

(3) (3) (4) (4) (1) (15)

NS NS NS NS NS NS

Control department, 11th month

7/89 3/89 0/89 16/89 5/89 9/89

(8) (3) (18) (6) (10)

P3,4

c2-test:

<0.05, <0.05 NS NS NS NS <0.01, NS

N ¼ 248

Fisher’s exact test:

6 2 6 13 3 30

NS NS NS <0.05 NS <0.001

(2) (1) (2) (5) (1) (12)

MRSA, meticillin-resistant S. aureus; VRE, vancomycin-resistant enterococcus; NS, non-significant. P1: differences between the first and last months of the study departments. P2: differences between the first and last months of the control departments. P3,4: differences between the study and control departments in the first month (P3) and the last month (P4). c2: see Statistical methods. This analysis allows simultaneous analysis of the three variables: group [study patients/control patients]  timing [pre/post intervention]  [nosocomial infection/no nosocomial infection]; the P-value shows that the significant decrease in nosocomial infections occurred between the first and last months of the study and only in the study departments. a Combined results from the three study departments and three control departments. b In the study departments 41 nosocomial infections were diagnosed in 37/345 (11%) patients in the first month, compared with 22 infections in 16/383 (4%) patients in the last month (P < 0.001). In the control department, 40 infections were diagnosed in 26/270 (10%) patients in the first month, compared with 30 infections in 21/248 (8%) patients in the last month (NS).

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Table III Adherence to infection control guidelines in the departments Variables

Hospital A

Written protocols 82/83 Knowledge of protocols 35/37 Isolation procedures 36/54 Kitchen maintenance 230/344 Departmental cleanliness 281/288 Instrument storage 216/216 Care of medical/regular waste 210/216 Care of laundry 108/108 Prevention of sharps injuries 263/285 Maintenance of sterile equipment 159/165 Sterilization solutions 32/32 Cleaning of patients’ beds/environments 204/287 Staff hand hygiene 316/426 Protective clothing and equipment 162/216 Care of central venous catheters NA Care of parenteral alimentation 15/17 Care of peripheral venous catheters 209/249 Care of urinary catheters 107/108 Care of intubated and ventilated patients 2/3 Suction equipment and procedures 0/4 Wound care 140/216 Total 2807/3355

(99%) (95%) (67%) (67%) (98%) (100%) (97%) (100%) (92%) (96%) (100%) (71%) (74%) (75%) (88%) (84%) (99%) (67%) (0%) (65%) (84%)

Hospital B 85/89 67/69 54/54 329/359 288/288 210/215 215/215 108/108 286/286 235/235 36/36 252/288 284/431 200/236 264/264 148/148 252/252 108/108 12/12 16/16 216/216 3670/3925

Hospital C

(96%) 41/41 (97%) 35/40 (100%) 32/47 (93%) 239/296 (100%) 204/239 (98%) 180/180 (100%) 129/161 (100%) 90/90 (100%) 230/240 (100%) 121/200 (100%) 10/11 (88%) 177/234 (66%) 136/336 (85%) 109/207 (100%) 39/61 (100%) 0/3 (100%) 119/159 (100%) 71/72 (100%) 30/30 (100%) 60/90 (100%) NA (94%) 2052/2737

(100%) (88%) (68%) (81%) (85%) (100%) (80%) (100%) (96%) (61%) (91%) (76%) (40%) (53%) (64%) (0%) (75%) (99%) (100%) (67%) (75%)

All 208/213 137/146 122/155 803/999 773/815 606/611 554/592 306/306 779/811 515/600 78/79 633/809 736/1193 471/659 303/326 163/168 580/660 286/288 44/45 76/110 356/432 8529/10,017

P (98%) (94%) (79%) (80%) (95%) (99%) (94%) (100%) (96%) (86%) (99%) (78%) (62%) (71%) (93%) (97%) (88%) (99%) (98%) (69%) (82%) (85%)

NS NS <0.001 <0.001 <0.001 <0.05 <0.001 NS <0.001 <0.001 <0.05 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 NS <0.01 <0.001 <0.001 <0.001

NS, not significant. P refers to the difference between the three hospitals.

walking in and out of the operating rooms during surgery (75  0%). Over time, the rate of adherence to guidelines increased from 80% to 87%. In the operating rooms, the baseline rate was an exceptional 96%, which then fell to 85%, and subsequently increased to 91%. According to the study design, these data were collected for the study departments only.

Discussion Infection control is becoming more complex as many evidence-based guidelines are being published. To simplify and increase adherence to these guidelines, our team developed two detailed checklists, one for inpatient departments and the other for operating rooms, both for the use of infection control practitioners. The comparison of one study medical department and two surgical departments, in which the checklists were used, with their respective control departments, demonstrated a decrease in nosocomial infections from 37/345 (11%) in the first month of the study, to 16/383 (4%) in the last month in study departments, but not in the control departments, a reduction of 21 infections. If 21 infections were prevented in the study departments each month during the study year, then an estimated 252 infections were prevented per year in only these three departments. Assuming a conservative case-fatality rate of 5% for nosocomial urinary tract and surgical site infections, the use of this programme may have prevented about 12 deaths in only three departments.22,23 Bloodstream infections and nosocomial pneumonia carry a mortality rate of 30%; therefore, the number of prevented deaths could have been considerably higher.24 The excess morbidity, increased duration of hospital stay and costs

associated with nosocomial infections should be added to the calculations. The success of checklists in preventing disasters in the airline industry is often cited. Checklists have been applied extensively in other professions too, such as building, finance and entrepreneurship.25 Checklists are also increasingly being used in medicine and were found effective in performance improvement and error prevention.26e28 An evidence-based intervention in 103 intensive care units in the Michigan Keystone ICU programme has resulted in a large sustained reduction in rates of catheter-related bloodstream infections.29 A checklist was an important tool in this complex educational and cultural intervention. Pronovost, a criticalcare specialist, was among the first who not only designed and implemented a simple checklist as a tool for infection prevention, but also recognized its power and possibilities. After the success of this tool in catheter-associated bloodstream infection prevention, Pronovost et al. evaluated checklists for pain control and for ventilator-associated pneumonia.29,30 Although they have abundantly demonstrated the benefit of application of checklists this approach has also met criticism. Some physicians are offended by the suggestion that they need checklists, while others are reluctant to allocate time for filling out the paperwork.25,31 In our study, use of the checklist was not the sole means for securing improved adherence with infection control guidelines and attaining a reduction in nosocomial infection rates. Rather, the checklist was part of a comprehensive programme, including education, data collection and issuing monthly reports providing feedback about performance, which altered the local culture in the participating departments. No

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Table IV Adherence to infection control guidelines in the operating rooms Variables General Organization and signs Maintenance Written protocols for cleaning Care of medical/regular waste Care of laundry Care of sharps and their disposal Maintenance of clean and sterile supplies Presence and use of sterilization solutions Staff hand hygiene Sterility of operating rooms Handling of sterile instruments during operations Ambulation in OR during surgery Observations of surgeons Observations of nurses Observations of anaesthetists Observations of anaesthetists’ assistants Observations of paramedical personnel Aseptic behaviour of anaesthesthetics team Overall behaviour in operating rooms Total

Hospital A 39/40 67/73 89/96 43/44 21/24 25/32 24/24 58/64 28/32 59/62 47/47 32/33 24/32 175/192 170/192 96/176 58/103 0/2 241/291 82/129 1278/1688

(97%) (92%) (93%) (98%) (88%) (78%) (100%) (91%) (88%) (95%) (100%) (97%) (75%) (91%) (89%) (55%) (56%) (0%) (83%) (64%) (82%)

Hospital B 45/45 89/90 123/124 54/54 27/27 36/36 27/27 72/72 29/29 66/72 63/63 40/45 27/36 198/216 195/216 189/222 130/163 0/1 346/349 141/161 1897/2048

(100%) (99%) (99%) (100%) (100%) (100%) (100%) (100%) (100%) (92%) (100%) (89%) (75%) (92%) (90%) (85%) (80%) (0%) (99%) (88%) (93%)

All 84/85 156/163 212/220 97/98 48/51 61/68 51/51 130/136 57/61 125/134 110/110 72/78 51/68 373/408 365/408 285/398 188/266 0/3 587/640 223/290 3275/3736

P (99%) (96%) (96%) (99%) (94%) (90%) (100%) (96%) (93%) (93%) (100%) (92%) (75%) (91%) (89%) (72%) (71%) (0%) (92%) (77%) (88%)

NS <0.05 <0.05 NS NS <0.01 NS <0.01 <0.05 NS NS NS NS NS NS <0.01 <0.01 NS <0.01 <0.01 <0.01

OR, operating room; NS, not significant. P refers to the difference between the two hospitals.

additional interventions were made such as change in availability of hand disinfectants: these have been present on all hospital beds and points of care from several years before the start of the study. Hospital boards also use checklists to guide the development of strategy plans for patients’ safety.30,32 Most interventions are accompanied by improvement in the outcome marker, but results often revert to pre-intervention status once the intervention is discontinued. Therefore, when combined with feedback of objective data and educational efforts, the checklist may have greatest value as an ongoing daily tool for persistent reduction of nosocomial infection rates, similar to its application in the airline industry and elsewhere. Three surrogate markers were used for nosocomial infections: antibiotic use, clinical culture reports, and personnel hand and environmental cultures. The use of surrogate markers can save a substantial amount of time and labour on the part of infection control practitioners, identifying and registering cases, before and after discharge from hospital. Although some studies have reported that electronic surveillance of postoperative antibiotic use may serve as a reliable alternative to infection surveillance, this study found no statistically significant trend in any of the measured surrogate markers during the 11 months of the study.33e35 Moreover, no significant correlation was detected between the decreasing rate of nosocomial infections, as measured directly, and the surrogate markers. It is uncertain which of the actions involved in the study was the most effective in infection prevention. The decrease in nosocomial infection rate may be attributed to the educational sessions, the ongoing feedback during the nurses’ rounds, the spirit of competition unleashed with the monthly reports, or perhaps even the Hawthorne effect. Our study has several limitations. First, data were collected on nosocomial infection rates in the first and last months in all

study and control departments rather than for the entire year. The nurses did not have sufficient time to work with the checklists in addition to the collection of data regarding nosocomial infections. A compromise was therefore adopted: the first and last months were dedicated to determination of infection control rates, whereas the intervening 10 months were dedicated to work with the checklist as outlined. In order to minimize the limitation of this pre/post design, each study department also had a matched control department, which served as simultaneous control to rule out confounding factors. Our results demonstrate that the study departments’ infection control rate decreased compared with their baseline rate, and also compared with that of the control departments. Second, significant monthly variations were found in the surrogate markers. Collection of larger amounts of data for each marker, by including more departments in the study or prolongation of the study period, could have reduced the variability and uncovered meaningful trends. However, these fluctuations probably reflect real-life differences in patients’ requirements. Third, the detailed checklist included about 150 items; hence, its size and application may meet with resistance in infection control practitioners. Therefore, the checklist should give infection practitioners the freedom to select items for more or less frequent evaluation. In addition, it should be reviewed frequently to reflect updates in evidence-based medicine.36 One significant advantage of the detailed checklist is that it allows experienced nurses without previous formal education in infection control to participate in hospital epidemiology and contribute to infection control. In summary, this programme demonstrated a significant reduction of nosocomial infection rate, from 11% in the first month to 4% in the last month in study departments, but not in concomitant control departments. The use of detailed

A.M. Yinnon et al. / Journal of Hospital Infection 81 (2012) 169e176 checklists and issuing of monthly reports to all relevant personnel was effective in reducing infection rates. Implementation of this approach may help further improve the quality of care and patients’ outcomes. Conflict of interest statement None declared.

14.

15.

Funding sources Supported by a grant from the Israeli Ministry of Health. 16.

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