Cost Analysis of a Hand Hygiene Improvement Strategy in Long-Term Care Facilities.

OBJECTIVES: To evaluate whether the costs of a successful tailored multifaceted strategy to improve hand hygiene compliance outweighed the savings by reducing infection costs in Dutch long-term care facilities (LTCFs). DESIGN: A retrospective cost analysis alongside a stepped-wedge cluster-randomized controlled trial. SETTING AND PARTICIPANTS: The study included 14 LTCFs (23 wards) in the Netherlands. METHODS: The cost analysis was based on the costs of the intervention vs the savings from avoided infections and associated treatment costs. Infection-related costs of the "usual-care" period were compared with the combined infection-related costs and intervention costs from the "intervention" period and the costs in the "post-intervention period." Multilevel analyses, with a linear model with periods as fixed effects, random effects for cluster LTCFs, and fixed effects for each step, were completed. RESULTS: There are no significant differences in total costs considering the 3 periods. When adjusting for time and clustering, the mean infection-related costs per week per LTCF for all the infections combined were highest during "usual-care" before the hand hygiene intervention was performed, namely 680 euros per week. Assuming the effect of the improvement strategy would be present for 12 months, the costs per week in the "intervention" and "post-intervention" periods were 627 euros (95% CI, 383-871) and 731 euros (95% CI, 508-954), respectively. Assuming the effect of the improvement strategy will last longer than 1 year (ie, 18 and 24 months), the average cost for the "intervention period" and the "post-intervention" period decreased to 615 euros and 719 euros during the intervention and 609 euros and 715 euros after the intervention, respectively. CONCLUSIONS AND IMPLICATIONS: Our multifaceted hand hygiene improvement strategy achieves cost savings. The results of our study are the first of an economic analysis of a hand hygiene improvement strategy in LTCFs. The results need to be confirmed by further economic evaluations.

Effects of de-implementation strategies aimed at reducing low-value nursing procedures: a systematic review and meta-analysis.

BACKGROUND: In the last decade, there is an increasing focus on detecting and compiling lists of low-value nursing procedures. However, less is known about effective de-implementation strategies for these procedures. Therefore, the aim of this systematic review was to summarize the evidence of effective strategies to de-implement low-value nursing procedures. METHODS: PubMed, Embase, Emcare, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar were searched till January 2020. Additionally, reference lists and citations of the included studies were searched. Studies were included that described de-implementation of low-value nursing procedures, i.e., procedures, test, or drug orders by nurses or nurse practitioners. PRISMA guideline was followed, and the 'Cochrane Effective Practice and Organisation of Care' (EPOC) taxonomy was used to categorize de-implementation strategies. A meta-analysis was performed for the volume of low-value nursing procedures in controlled studies, and Mantel-Haenszel risk ratios (95% CI) were calculated using a random effects model. RESULTS: Twenty-seven studies were included in this review. Studies used a (cluster) randomized design (n = 10), controlled before-after design (n = 5), and an uncontrolled before-after design (n = 12). Low-value nursing procedures performed by nurses and/or nurse specialists that were found in this study were restraint use (n = 20), inappropriate antibiotic prescribing (n = 3), indwelling or unnecessary urinary catheters use (n = 2), ordering unnecessary liver function tests (n = 1), and unnecessary antipsychotic prescribing (n = 1). Fourteen studies showed a significant reduction in low-value nursing procedures. Thirteen of these 14 studies included an educational component within their de-implementation strategy. Twelve controlled studies were included in the meta-analysis. Subgroup analyses for study design showed no statistically significant subgroup effect for the volume of low-value nursing procedures (p = 0.20). CONCLUSIONS: The majority of the studies with a positive significant effect used a de-implementation strategy with an educational component. Unfortunately, no conclusions can be drawn about which strategy is most effective for reducing low-value nursing care due to a high level of heterogeneity and a lack of studies. We recommend that future studies better report the effects of de-implementation strategies and perform a process evaluation to determine to which extent the strategy has been used. TRIAL REGISTRATION: The review is registered in Prospero (CRD42018105100).

Explaining the effects of two different strategies for promoting hand hygiene in hospital nurses: a process evaluation alongside a cluster randomised controlled trial.

BACKGROUND: There is only limited understanding of why hand hygiene improvement strategies are successful or fail. It is therefore important to look inside the 'black box' of such strategies, to ascertain which components of a strategy work well or less well. This study examined which components of two hand hygiene improvement strategies were associated with increased nurses' hand hygiene compliance. METHODS: A process evaluation of a cluster randomised controlled trial was conducted in which part of the nursing wards of three hospitals in the Netherlands received a state-of-the-art strategy, including education, reminders, feedback, and optimising materials and facilities; another part received a team and leaders-directed strategy that included all elements of the state-of-the-art strategy, supplemented with activities aimed at the social and enhancing leadership. This process evaluation used four sets of measures: effects on nurses' hand hygiene compliance, adherence to the improvement strategies, contextual factors, and nurses' experiences with strategy components. Analyses of variance and multiple regression analyses were used to explore changes in nurses' hand hygiene compliance and thereby better understand trial effects. RESULTS: Both strategies were performed with good adherence to protocol. Two contextual factors were associated with changes in hand hygiene compliance: a hospital effect in long term (p < 0.05), and high hand hygiene baseline scores were associated with smaller effects (p < 0.01). In short term, changes in nurses' hand hygiene compliance were positively correlated with experienced feedback about their hand hygiene performance (p < 0.05). In the long run, several items of the components 'social influence' (i.e., addressing each other on undesirable hand hygiene behaviour p < 0.01), and 'leadership' (i.e., ward manager holds team members accountable for hand hygiene performance p < 0.01) correlated positively with changes in nurses' hand hygiene compliance. CONCLUSION: This study illustrates the use of a process evaluation to uncover mechanisms underlying change in hand hygiene improvement strategies. Our study results demonstrate the added value of specific aspects of social influence and leadership in hand hygiene improvement strategies, thus offering an interpretation of the trial effects. TRIAL REGISTRATION: The study is registered in ClinicalTrials.gov, dossier number: NCT00548015.

Cost-effectiveness of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial.

BACKGROUND: Many strategies have been designed and evaluated to address poor hand hygiene compliance. Unfortunately, well-designed economic evaluations of hand hygiene improvement strategies are lacking. OBJECTIVE: To compare the cost-effectiveness of two successful implementation strategies for improving nurses' hand hygiene compliance and reducing hospital acquired infections (HAI's). DESIGN AND SETTING: A cost-effectiveness analysis alongside a cluster randomised controlled trial was conducted in 67 nursing wards of three hospitals in the Netherlands. The evaluation used a hospital perspective. PARTICIPANTS: All affiliated nurses of the nursing wards. Wards were randomly assigned to either the control group (n=30) or the experimental group (n=37). METHODS: The control group received a state-of-the-art strategy including education, reminders feedback and optimising materials and facilities. The experimental group received a team and leaders-directed strategy which included all elements of the state-of-the-art strategy supplemented with interventions aimed at the social context of teams and enhancing leadership. The most efficient implementation strategy was determined by the incremental cost-effectiveness ratio per extra percentage of hand hygiene compliance gained and the incremental cost-effectiveness ratio per additional percentage reduction in the HAI rate. Bootstrap methods were used to determine confidence intervals for these incremental cost-effectiveness ratio's. Two scenarios of 15 and 30% were used to express the association between increased hand hygiene compliance and the reduction in HAIs. RESULTS: The team and leaders-directed strategy was significantly more effective in improving hand hygiene compliance. The mean difference effect was 8.91% (95% CI, 0.75-17.06). This extra increase was achieved at an average cost of €5497 per ward. The incremental cost per extra percentage of hand hygiene gained on ward level was €622. The incremental cost per additional percentage reduction in the HAI rate on ward level was €2074 (30% scenario) and €4125 (15% scenario). Within the 30% scenario, there is a probability of 90% that the team and leaders-directed strategy is cost-effective and within the 15% scenario, there is a probability of 70% that the team and leaders-directed strategy is cost-effective. CONCLUSIONS: Optimising hand hygiene compliance through a team and leaders-directed strategy is cost-effective as compared to a state-of-the-art strategy.

Helping hands: a cluster randomised trial to evaluate the effectiveness of two different strategies for promoting hand hygiene in hospital nurses.

BACKGROUND: Hand hygiene prescriptions are the most important measure in the prevention of hospital-acquired infections. Yet, compliance rates are generally below 50% of all opportunities for hand hygiene. This study aims at evaluating the short- and long-term effects of two different strategies for promoting hand hygiene in hospital nurses. METHODS/DESIGN: This study is a cluster randomised controlled trial with inpatient wards as the unit of randomisation. Guidelines for hand hygiene will be implemented in this study. Two strategies will be used to improve the adherence to guidelines for hand hygiene. The state-of-the-art strategy is derived from the literature and includes education, reminders, feedback, and targeting adequate products and facilities. The extended strategy also contains activities aimed at influencing social influence in groups and enhancing leadership. The unique contribution of the extended strategy is built upon relevant behavioural science theories. The extended strategy includes all elements of the state-of-the-art strategy supplemented with gaining active commitment and initiative of ward management, modelling by informal leaders at the ward, and setting norms and targets within the team. Data will be collected at four points in time, with six-month intervals. An average of 3,000 opportunities for hand hygiene in approximately 900 nurses will be observed at each time point. DISCUSSION: Performing and evaluating an implementation strategy that also targets the social context of teams may considerably add to the general body of knowledge in this field. Results from our study will allow us to draw conclusions on the effects of different strategies for the implementation of hand hygiene guidelines, and based on these results we will be able to define a preferred implementation strategy for hospital based nursing. TRIAL REGISTRATION: The study is registered as a Clinical Trial in ClinicalTrials.gov, dossier number: NCT00548015.

The ACCOMPLISH study. A cluster randomised trial on the cost-effectiveness of a multicomponent intervention to improve hand hygiene compliance and reduce healthcare associated infections.

BACKGROUND: Public health authorities have recognized lack of hand hygiene in hospitals as one of the important causes of preventable mortality and morbidity at population level. The implementation strategy ACCOMPLISH (Actively Creating COMPLIance Saving Health) targets both individual and environmental determinants of hand hygiene. This study aims to evaluate the cost-effectiveness of a multicomponent implementation strategy aimed at the reduction of healthcare associated infections in Dutch hospital care, by promotion of hand hygiene. METHODS/DESIGN: The ACCOMPLISH package will be evaluated in a two-arm cluster randomised trial in 16 hospitals in the Netherlands, in one intensive care unit and one surgical ward per hospital. INTERVENTION: A multicomponent package, including e-learning, team training, introduction of electronic alcohol based hand rub dispensers and performance feedback. VARIABLES: The primary outcome measure will be the observed hand hygiene compliance rate, measured at baseline and after 6, 12 and 18 months; as a secondary outcome measure the prevalence of healthcare associated infections will be measured at the same time points. Process indicators of the intervention will be collected pre and post intervention. An ex-post economic evaluation of the ACCOMPLISH package from a healthcare perspective will be performed. STATISTICAL ANALYSIS: Multilevel analysis, using mixed linear modelling techniques will be conducted to assess the effect of the intervention strategy on the overall compliance rate among healthcare workers and on prevalence of healthcare associated infections. Questionnaires on process indicators will be analysed with multivariable linear regression, and will include both behavioural determinants and determinants of innovation. Cost-effectiveness will be assessed by calculating the incremental cost-effectiveness ratio, defined here as the costs for the intervention divided by the difference in prevalence of healthcare associated infections between the intervention and control group. DISCUSSION: This study is the first RCT to investigate the effects of a hand hygiene intervention programme on the number of healthcare associated infections, and the first to investigate the cost-effectiveness of such an intervention. In addition, if the ACCOMPLISH package proves successful in improving hand hygiene compliance and lowering the prevalence of healthcare associated infections, the package could be disseminated at (inter)national level. TRIAL REGISTRATION: NTR2448.

Pain management: a review of organisation models with integrated processes for the management of pain in adult cancer patients.

AIMS AND OBJECTIVES: This paper reports a review of the literature conducted to identify organisation models in cancer pain management that contain integrated care processes and describe their effectiveness. BACKGROUND: Pain is experienced by 30-50% of cancer patients receiving treatment and by 70-90% of those with advanced disease. Efforts to improve pain management have been made through the development and dissemination of clinical guidelines. Early improvements in pain management were focussed on just one or two single processes such as pain assessment and patient education. Little is known about organisational models with multiple integrated processes throughout the course of the disease trajectory and concerning all stages of the care process. DESIGN: Systematic review. METHOD: The review involved a systematic search of the literature, published between 1986-2006. Subject-specific keywords used to describe patients, disease, pain management interventions and integrated care processes, relevant for this review were selected using the thesaurus of the databases. CONCLUSION: Institutional models, clinical pathways and consultation services are three alternative models for the integration of care processes in cancer pain management. A clinical pathway is a comprehensive institutionalisation model, whereas a pain consultation service is a 'stand-alone' model that can be integrated in a clinical pathway. Positive patient and process outcomes have been described for all three models, although the level of evidence is generally low. Evaluation of the quality of pain management must involve standardised measurements of both patient and process outcomes. RELEVANCE TO CLINICAL PRACTICE: We recommend the development of policies for referrals to a pain consultation service. These policies can be integrated within a clinical pathway. To evaluate the effectiveness of pain management models standardised outcome measures are needed.