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Background Care bundles have proven to be effective in improving clinical outcomes. It is not known which strategies are the most effective to implement care bundles. A systematic review was conducted to determine the strategies used to implement care bundles in adult intensive care units and to assess the effects of these strategies when implementing bundles. Methods The databases MEDLINE/PubMed, Ovid/Embase, CINAHL and CENTRAL were searched for eligible studies until January 31, 2015. Studies with (non)randomised designs on central line, ventilator or sepsis bundles were included if implementation strategies and bundle compliance were reported. Methodological quality was assessed by using the Downs and Black checklist. Data extraction and quality assessments were independently performed by two reviewers. Results In total, 1533 records were screened and 47 studies were finally included. In 49 %, pre/post designs were used, 38 % prospective cohorts, and the remaining studies used retrospective designs (6 %), interrupted time series (4 %) and longitudinal designs (2 %). The methodological quality was classified as ‘fair’ in 77 %, and the remaining as ‘good’ (13 %) and ‘poor’ (11 %). The most frequently used strategies were education (86 %), reminders (71 %) and audit and feedback (63 %). Our results show that compliance is influenced by multiple factors, i.e. types and numbers of elements varied and different compliance measurements were reported. Furthermore, compliance was calculated within different time frames. Also, detailed information about compliance, such as numerators and denominators, was not reported. Therefore, recalculation of consistent monthly compliance levels was not possible. Conclusions The three most frequently used strategies were education, reminders and audit and feedback. We conclude that the heterogeneity among the included studies was high due to the variety in study designs, number and types of elements and types of compliance measurements. Due to the heterogeneity of the data and the poor quality of the studies, conclusions about which strategy results in the highest levels of bundle compliance could not be determined. We strongly recommend that studies in quality improvement should be reported in a formalised way in order to be able to compare research findings. It is imperative that authors follow the standards for quality improvement reporting excellence (SQUIRE) guidelines whenever they report quality improvement studies.

Catheter-associated bloodstream infections and urinary tract infections are frequently encountered health care-associated infections. We aimed to reduce inappropriate use of catheters to reduce health care-associated infections. In this multicentre, interrupted time-series and before and after study, we introduced a de-implementation strategy with multifaceted interventions in seven hospitals in the Netherlands. Adult patients admitted to internal medicine, gastroenterology, geriatic, oncology, or pulmonology wards, and non-surgical acute admission units, and who had a (central or peripheral) venous or urinary catheter were eligible for inclusion. One of the interventions was that nurses in the participating wards attended educational meetings on appropriate catheter use. Data on catheter use were collected every 2 weeks by the primary research physician during the baseline period (7 months) and intervention period (7 months), which were separated by a 5 month transition period. The primary outcomes were percentages of short peripheral intravenous catheters and urinary catheters used inappropriately on the days of data collection. Indications for catheter use were based on international guidelines. This study is registered with Netherlands Trial Register, NL5438. Between Sept 1, 2016, and April 1, 2018, we screened 6157 patients for inclusion, of whom 5696 were enrolled: 2650 patients in the baseline group, and 3046 in the intervention group. Inappropriate use of peripheral intravenous catheters occurred in 366 (22·0%, 95% CI 20·0 to 24·0) of 1665 patients in the baseline group and in 275 (14·4%, 12·8 to 16·0) of 1912 patients in the intervention group (incidence rate ratio [IRR] 0·65, 95% CI 0·56 to 0·77, p<0·0001). Time-series analyses showed an absolute reduction in inappropriate use of peripheral intravenous catheters from baseline to intervention periods of 6·65% (95% CI 2·47 to 10·82, p=0·011). Inappropriate use of urinary catheters occurred in 105 (32·4%, 95% CI 27·3 to 37·8) of 324 patients in the baseline group compared with 96 (24·1%, 20·0 to 28·6) of 398 patients in the intervention group (IRR 0·74, 95% CI 0·56 to 0·98, p=0·013). Time-series analyses showed an absolute reduction in inappropriate use of urinary catheters of 6·34% (95% CI −12·46 to 25·13, p=0·524). Our de-implementation strategy reduced inappropriate use of short peripheral intravenous catheters in patients who were not in the intensive care unit. The reduction of inappropriate use of urinary catheters was substantial, yet not statistically significant in time-series analysis due to a small sample size. The strategy appears well suited for broad-scale implementation to reduce health care-associated infections. Netherlands Organisation for Health Research and Development.

Background Urinary and (peripheral and central) intravenous catheters are widely used in hospitalized patients. However, up to 56% of the catheters do not have an appropriate indication and some serious complications with the use of these catheters can occur. The main objective of our quality improvement project is to reduce the use of catheters without an appropriate indication by 25–50%, and to evaluate the affecting factors of our de-implementation strategy. Methods In a multicenter, prospective interrupted time series analysis, several interventions to avoid inappropriate use of catheters will be conducted in seven hospitals in the Netherlands. Firstly, we will define a list of appropriate indications for urinary and (peripheral and central) intravenous catheters, which will restrict the use of catheters and urge catheter removal when the indication is no longer appropriate. Secondly, after the baseline measurements, the intervention will take place, which consists of a kick-off meeting, including a competitive feedback report of the baseline measurements, and education of healthcare workers and patients. Additional strategies based on the baseline data and local conditions are optional. The primary endpoint is the percentage of catheters with an inappropriate indication on the day of data collection before and after the de-implementation strategy. Secondary endpoints are catheter-related infections or other complications, catheter re-insertion rate, length of hospital (and ICU) stay and mortality. In addition, the cost-effectiveness of the de-implementation strategy will be calculated. Discussion This study aims to reduce the use of urinary and intravenous catheters with an inappropriate indication, and as a result reduce the catheter-related complications. If (cost-) effective it provides a tool for a nationwide approach to reduce catheter-related infections and other complications. Trial registration Dutch trial registry: NTR6015 . Registered 9 August 2016.

Background Catheter-associated urinary tract infection (UTI) and catheter-associated bloodstream infection (BSI) are common healthcare-associated infections (HAI). Therefore, catheters should only be used if indicated. However, based on the literature up to 65% of the urinary catheters and 56% of the peripheral intravenous catheters have an inappropriate indication. So, an efficient way to reduce HAIs is to avoid unnecessary use of catheters. Our quality improvement project aims to reduce unnecessary use of catheters. Methods In a multicenter, interrupted time series study, several interventions to avoid inappropriate use of catheters were carried out in internal medicine and nonsurgical subspecialty wards in seven hospitals in the Netherlands. The indications for catheter use were based on (inter)national guidelines. The primary endpoint is the percentage of inappropriate indications on the day of data collection. Secondary endpoints are catheter-associated infections, length of hospital stay and mortality. Data were collected once per 2 weeks during baseline (7 months) and post-intervention (7 months). Preliminary analyses compared incidence rates before and after the intervention. Results Data were obtained from 5,691 observed patients. The rate of inappropriate use of urinary catheters decreased from 32.1 to 23.7% (incidence rate ratio 0.74, 95% CI 0.58–0.94, P = 0.013), and inappropriate use of peripheral intravenous catheters decreased from 22.0 to 15.2% (incidence rate ratio 0.69, 95% CI 0.60–0.80, P < 0.001). The overall urinary and intravenous catheter use was stable, resp. 12.2% (n = 324) to 12.5% (n = 380) and 62.8% (n = 1,665) to 62.1% (n = 1,887). Most inappropriate indications were due to prolonged catheter use. The indications which expire frequently are”Accurate measurements of urinary output in critically ill patients’ for urinary and”IV fluids and antibiotic therapy’ for intravenous catheters. Subsequent analyses will take into account the interrupted time series design, and evaluate catheter-associated UTI and BSI rates. Conclusion Our de-implementation strategy reduces unnecessary use of urinary and intravenous catheters in non-ICUs. It is important to increase awareness for inappropriate use of catheters. Disclosures S. E. Geerlings, Nordic Pharma: Consultant and Fosfomycin iv, consulting fee.