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The rate of change in reduction in infection rates did not accelerate following the second training day. For adult ICUs, each successive cluster to join the project had an entry-level infection rate close to the post-intervention level of the preceding cluster figure 1 D Z statistic 1.
Late engagement cluster 4 was not associated with poorer performance in any metric. Numbers were too small, and the variation in infection rates too great, to draw secure conclusions from the paediatric data figure 1 F. The trend for reduction in infection rates was not associated with hospital type or the number of CVC-patient days for either adult or paediatric ICUs. CVC utilisation ratios could only be determined from December ; utilisation rates remained stable Attendance at both training days was achieved by ICUs Twenty-eight of 45 ICUs responded to an invitation to participate in data verification and 17 actually participated one paediatric ICU, two university, 14 adult general.
Reasons for non-participation included no response to further contacts 10 , clinical workload 3 , inadequate administrative support 4 , absence of timely authority to access medical records 7 , and inadequate project team resources 4.
Criterion-referenced case note review was conducted in patients with positive BCs; in 54 patients External adjudication agreed with local adjudication in instances seven reclassified as attributable, three as non-attributable, overall correct classification The kappa for agreement between local and external adjudicators was 0.
The method did not permit determination of CVC infection in the absence of a blood culture. On initial examination, and using the metrics employed by the majority of studies in this area, Matching Michigan was a success. Closer examination of the data reveals a more complex picture requiring a nuanced interpretation. First, each successive cluster joined the project on the trend line for the post-intervention level of the preceding cluster, thus indicating a strong secular trend.
These findings suggest the possibility that the reduction in infection rates could be attributable as much to concurrent and preceding improvement efforts and to the consciousness-raising effect of a nationwide programme as to any specific component of the Matching Michigan programme itself.
This study is an example of the challenges of conducting field evaluations of complex interventions to improve care in real time in rapidly moving fields. Our stepped before and after design reduces the risk of bias, 39 and the analysis therefore emphasises the need for caution in attributing the reduction in infection rates to specific elements in the programme.
Lack of a specific causative link between complex behavioural interventions and improved outcomes has been reported for end-of-life care, 40 stroke care, 33 coronary balloon angioplasty 34 and multifaceted safety programmes, 35 while others have reported strong secular trends for improvement in CVC-BSI rates in conjunction with national reporting but in the absence of specific targeted interventions.
Study designs involving randomisation, which could help to determine quality improvement programme effects more precisely, are challenged by ethical considerations when best practice is already well established, and practical considerations of isolating intervention from controls. Cluster-randomised designs are particularly important for interventions involving behavioural change, 40 , 42 since the component elements may be rooted in specific cultures, locations and periods, and require testing in the same way as a pharmaceutical intervention in a new population.
A design such as that used in our study—involving clusters joining in a pre-determined sequence, with each successive cluster acting as a de facto control for the preceding cluster—although not formally randomised is one of the more robust approaches that can feasibly be deployed.
However, it is subject to a number of threats to internal validity. It is also possible that the reduction in reported rates of infections may to some extent have been an artefact of reporting behaviours, since data were collected and reported by ICUs themselves and may have been influenced by perceptions of external scrutiny and performance management.
A further limitation of our study was the absence of measures of adoption of the interventions and compliance with best practice.
Several studies have reported an association between higher compliance and lower infection rates, 47—49 but data completeness and the methods chosen for compliance monitoring are rarely described in detail, and the literature on hand hygiene demonstrates poor correlation between self-reported and observed compliance.
The data verification sub-study provides some reassurance of validity in relation to reporting behaviours, but also demonstrates considerable variability in local practices in relation to CVC use and intensity of sampling blood for culture.
Variability in surveillance techniques is well recognised and substantially alters reported infection rates. These factors make direct comparison between ICUs challenging. Harmonisation of practice would reduce the risk of confounding, and could bring additional benefits in reducing nosocomial infection rates.
Such programmes may have a particular role in raising awareness, increasing the intensity of focus and stimulating managerial support for professional activities. Feedback of infection rates may have promoted more reliable provision of and adherence to the well known technical aspects of infection prevention for CVCs. Understanding more precisely how such programmes work remains an important task, since such understanding is likely to avoid inappropriate and ineffective interventions, optimise delivery and improve effectiveness.
Differences included amendments to some of the programme materials to ensure contextual relevance; definitions of CVC-BSIs were specified more precisely; and the programme was directed by a government agency with advisory clinician input, not as a clinician-led collaborative. Contextual variability was also evident: Matching Michigan was, unlike Michigan-Keystone, implemented following extensive prior national efforts to improve practice, in a national health system in which intensive care specialists direct infection management with input from microbiology, as opposed to this being the domain of independent infection control practitioners.
Reduced rates of infection will deliver health gains for patients and benefits for health systems. The apparent trend for a reduction in CVC-BSIs acquired before ICU admission should not encourage complacency, however, 54 since in the absence of a denominator, conclusions cannot be drawn about rates of infection and quality of care. This study adds to the science of improvement by using a quasi-experimental design that reveals the significance of underlying secular trends but does not rule out the possibility that the programme itself was implicated in that trend.
Future studies should use robust mixed-methods research methodologies to clarify causal mechanisms underpinning quality improvement interventions, and to identify those most likely to promote more reliable delivery of best practice throughout the healthcare system, as well as promoting clinician ownership. East Surrey Hospital: Mary Sexton. Good Hope Hospital: Maung Kyi. Princess Alexandra Hospital: Rajnish Saha. Royal Brompton Hospital: Eva Zizkova.
Sandwell Hospital: Jana Bellin. Scunthorpe General Hospital: Jerry Thomas. This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author s and has not been edited for content. Contributors All collaborators are listed in the appendix. All authors contributed to the design and execution of the study, and all contributed to the interpretation of results. Funding The Department of Health provided some analytical data processing assistance at the end of the study.
The National Patient Safety Agency was responsible for directing the study. Statement of independence of researchers from funders: the statistical analysis and clinical interpretation of results of the study was performed independently of the Department of Health.
Ethicas approval The National Research Ethics Committee waived the requirement for informed patient consent on the basis that the intent was to improve uptake of established best practice care, and no patient-identifiable information would be collected centrally.
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Advanced search. Latest content Current issue Archive Authors About. Log in via Institution. When completed the space will transform a vacant lot between the Historical Society Museum and the Aspirus Ontonagon Fitness Center into an inclusive pocket park and a wall mural that will bring the history of the Ontonagon area alive. This project will replace an eyesore with an accessible outdoor space which will greatly enhance downtown Ontonagon.
When the RICC Park and Phase I of the OCHS Mural are completed, the community will feature an inviting outdoor art space that provides a backdrop for presentations by members of the historical society, local musicians, and other small groups. The pocket park will be a space used by Ontonagon visitors waiting to go on lighthouse tours or provide a place for visitors and village residents to have a picnic lunch.
The following report has been assembled for members following the last meeting. The Matching Michigan website is now live with uploaded documents. There have also been funding opportunities made available for healthcare professionals to undertake small scale changes within their own units to improve patient care.
Information and application form for this funding can be found in the Matching Michigan section at www.
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