Beruflich Dokumente
Kultur Dokumente
abstract
OBJECTIVE To determine the effectiveness of a short-term intervention to promote best practices for
control of respiratory infections in primary care physicians’ offices.
MAIN OUTCOME MEASURES Percentage of patients asked to use masks and alcohol-based hand gel, number
of relevant signs, and percentage of patients asked to sit at least 1 m away from other patients. Percentage of
surfaces disinfected and percentage of physicians using hand-gel dispensers in examining rooms.
RESULTS Of 242 practices invited, 53 agreed to participate (22% response rate), and within those practices,
143/151 (95%) physicians participated. Signs regarding respiratory infection control measures increased from
15.4% to 81.1% following the intervention (P < .001). At least 1 patient with cough and fever was given a mask
in 17% of practices before the intervention; during the observation period after the intervention, at least 1
patient was given a mask in 66.7% of practices (P < .001). Patients were instructed to use alcohol-based hand
gel in 24.5% of practices before the intervention and in 79.2% of practices after it (P < .001). Instruction to sit at
least 1 m from others in the waiting area was given in
39.6% of practices before the intervention and in 52.8% Editor’s key points
of practices following the intervention (P < .001). Before • This study assessed whether a short-term outreach
the intervention, the percentage of practices using all intervention was effective in improving practices for
4 audited primary prevention measures was 3.8%; after controlling respiratory infections in family physi-
the intervention, 52.8% of practices were using them cians’ offices.
(P < .001), demonstrating a 49% increase in adoption of • Outcomes were the percentage of offices following
best practices. the 4 observed infection-control practices (masks,
CONCLUSION A multifaceted intervention by public alcohol gel, spaced seating, and signs) and the 2
health nurses successfully promoted best practices reported infection-control practices (disinfection of
for control of respiratory infections in primary care potentially contaminated surfaces and use of hand-
offices. Collaboration between public health services gel dispensers in examining rooms).
and primary care can promote best practices and • Before the intervention, all 4 infection-control prac-
warrants further study and development in areas of tices were observed in fewer than 4% of offices; 6
common interest. weeks following the intervention, more than 50% of
offices were using the infection-control practices.
• This study is the first to use a facilitator-based inter-
This article has been peer reviewed. vention to promote guidelines for control of respira-
Full text available in English at www.cfpc.ca/cfp tory infections.
Can Fam Physician 2006;52:1110-1111
Vol 52: september • septembre 2006 Canadian Family Physician • Le Médecin de famille canadien 1111
Résumés de recherche
Résumé imprimé, texte sur le web
RÉSUMÉ
OBJECTIF Évaluer l’efficacité d’une intervention à court terme pour promouvoir des pratiques exemplaires visant le
contrôle des infections respiratoires dans les cabinets de médecins de première ligne.
PRINCIPAUX PARAMÈTRES ÉTUDIÉS Pourcentage des patients à qui on a demandé d’utiliser des masques et du gel
alcoolisé pour les mains, nombres d’affiches pertinentes et pourcentage des patients à qui on a demandé de s’asseoir à
au moins 1 mètre de distance des autres patients. Pourcentage des surfaces désinfectées et pourcentage des médecins
qui utilisent les dispensateurs de gel pour les mains dans les salles d’examen.
RÉSULTATS Des 242 cabinets invités, 53 ont accepté de participer (taux de réponse de 22%). Dans les 53 cabinets
participants, 143 médecins sur 151 (95%) ont pris part à l’étude. Le nombre d’affiches sur les mesures de contrôle des
infections respiratoires a augmenté de 15,4% à 81,1% à la suite de l’intervention (P < ,001). Au moins 1 patient présentant
de la toux et de la fièvre a reçu un masque dans 17% des
cabinets avant l’intervention; durant la période d’observation Points de repère du rédacteur
après l’intervention, au moins 1 patient a reçu un masque
• Cette étude évaluait l’efficacité d’une intervention
dans 66,7% des cabinets (P < ,001). Avant l’intervention, on
demandait aux patients d’utiliser du gel alcoolisé pour les de sensibilisation à court terme pour améliorer les
mains dans 24,5% des cabinets et, après l’intervention, ce pratiques de contrôle des infections respiratoires
pourcentage est passé à 79,2% (P < .001). On conseillait dans des cabinets de médecins de famille.
aux patients de s’asseoir à au moins 1 mètre les uns des • Les résultats étaient mesurés en fonction du pour-
autres dans 39,6% des cabinets avant l’intervention et,
après l’intervention, cette pratique était suivie dans 52,8%
centage de cabinets qui suivaient les 4 pratiques
des cabinets (P < ,001). Avant l’intervention, le pourcentage de contrôle des infections à l’étude (masque, gel
des cabinets qui respectaient les 4 mesures de prévention alcoolisé, espace entre les patients, et affiches) et
à l’étude se situait à 3,8%; après l’intervention, 52,8% des les 2 pratiques de contrôle des infections signalées
cabinets (P < ,001) avaient adopté ces pratiques exemplaires, (désinfection des surfaces possiblement infectées et
soit une augmentation de 49%.
utilisation des dispensateurs de gel alcoolisé dans les
CONCLUSION Une intervention à multiples facettes salles d’examen).
entreprise par des infirmières en santé publique a permis de • Avant l’intervention, les 4 pratiques de contrôle
promouvoir avec succès des pratiques exemplaires pour le
contrôle des infections respiratoires dans des cabinets de
des infections étaient observées dans moins de 4%
soins de première ligne. La collaboration entre les services des cabinets; 6 semaines après l’intervention, plus
de santé publique et les soins de première ligne favorise des de 50% des cabinets respectaient ces pratiques de
pratiques exemplaires, et mérite d’être étudiée plus à fond et contrôle des infections.
élargie dans les domaines d’intérêts communs. • Cette étude est la première à avoir mis à l’essai une
intervention utilisant un facilitateur pour promou-
Cet article a fait l’objet d’une révision par des pairs. voir les guides de pratique en matière de contrôle
Le texte intégral est accessible en anglais à www.cfpc.ca/cfp des infections respiratoires.
Can Fam Physician 2006;52:1110-1111.
1110 Canadian Family Physician • Le Médecin de famille canadien Vol 52: september • septembre 2006
Research Promoting best practices for control of respiratory infections
S
evere acute respiratory syndrome (SARS) disturbed having trained professionals working directly with phy-
the medical community’s complacency about con- sicians in their offices and uses audit of current practice,
trol of respiratory infections. Severe acute respira- evidence-based best practices, planning and consen-
tory syndrome disproportionately affected health care sus building, and feedback on performance change as
workers and innocent bystander patients1,2 and revealed means to improve practice.23 Several randomized con-
the potential for spread of respiratory infection in pri- trolled trials have shown outreach facilitation to be suc-
mary care offices.3 More recently, occurrences of avian cessful in improving delivery of preventive services and
influenza in Asia, Europe, and North America with occa- prescribing.24-28 One trial done in Ontario29 showed an
sional spread to humans has increased concern about absolute change of 11.5%, or a relative improvement
the risk of pandemic influenza.4 Added to these concerns of 36%, in preventive practices after an intervention, a
is the recognition that common microbial pathogens are result similar to those found in comparable trials.20,30-35
becoming increasingly resistant to antimicrobial therapy. In keeping with the post-SARS recommendation that
In the face of a re-emerging threat of respiratory infec- primary care and public health services work more col-
tions, prevention is increasingly important. laboratively,36 this research was a joint initiative of the
Several guidelines on control of respiratory infections University of Ottawa’s Family Medicine Department and
were issued both before and after SARS.5-10 Guidelines, the City of Ottawa’s Public Health Branch. We trained
however, are not always implemented. There is a public health nurses in outreach facilitation so they
well documented gap between what ought to be done could conduct the intervention. We evaluated both pro-
and what is being done. It is now clear that programs cess and outcomes. This paper focuses on outcomes.
designed only to increase physicians’ knowledge, such Our study was designed to assess whether a short-term
as traditional continuing medical education courses, are outreach facilitated intervention could be effective in
ineffective in changing physicians’ behaviour.11-13 improving practices for control of respiratory infections
Growing evidence indicates that interventions involv- in family physicians’ offices.
ing multiple strategies are more likely to result in
improved practice behaviour than single-strategy inter-
ventions are.14-18 Bero et al19 looked at 18 systematic METHODS
reviews covering more than 400 research papers on
improving professional performance and concluded that Setting
multifaceted facilitation interventions are effective in Ottawa, Ont, is a bilingual city with a population of
persuading physicians to incorporate good preventive approximately 800 000 people living in both urban and
practices into routine care. More recent reviews20-22 indi- rural areas. The study was conducted between February
cate that more research is needed to clarify whether and May 2004.
multifaceted interventions are better than single inter-
ventions. Interventions tailored to overcome barriers Study population
appear to be the most effective. We identified all 638 family physicians in 242 practices
One of the most effective multifaceted strategies in Ottawa and faxed them an invitation to join the study.
is outreach facilitation. Outreach facilitation involves Nonrespondents received a second fax and a follow-up
telephone call. Because of time constraints (the project
Dr Hogg is Director of Research in the Department of had to be implemented in 12 weeks), participating prac-
Family Medicine at the University of Ottawa in Ontario. tices were self-selected. Recruitment continued until
Dr Huston was Associate Medical Officer of Health the required number of practices had been enrolled.
for the City of Ottawa and an Adjunct Professor of We estimated that a sample of 49 practices would have
Epidemiology and Community Medicine at the University 95% power to detect a 15% improvement in the primary
of Ottawa at the time of the study. Dr Martin is Associate outcome measures. We included practices with 2 or
Professor of Family Medicine at the Northern Ontario more physicians participating in the study even if not
School of Medicine and an Adjunct Professor at the all doctors in the office agreed to participate. The small-
Indigenous Peoples’ Health Research Centre at the First est clinically significant difference was determined to be
Nations University of Canada. Dr Saginur practises a 15% improvement in practices for control of respira-
in the Department of Medicine at the Ottawa Hospital. tory infections. All practices joining the study gave writ-
Ms Newbury was Program Planning and Evaluation ten consent. The study was approved by the Ottawa
Officer in the City of Ottawa’s Mandatory Evaluation Hospital’s Research Ethics Board.
and Development Unit at the time of the study. Ms Vilis
was Facilitator Coordinator at the time of the study, and Identification of best practices
Dr Soto is Research Manager, in the Department of At the time of our intervention, there were Ontario
Family Medicine at the Institute of Population Health at guidelines on best practices for control of respiratory
the University of Ottawa. infections in hospitals37 and long-term care facilities38
Promoting best practices for control of respiratory infections Research
but not in ambulatory care settings. We convened an practices for control of respiratory infections, a poster
Expert Advisory Committee to review literature from the demonstrating proper hand-washing technique and use
Cochrane Library database; medical literature databases of alcohol-based gel, references listing the main sources
(MEDLINE); and major guideline, public health, and rel- of guidelines and websites, 4 articles on infection con-
evant professional association websites in Canada and trol,6-9 a box of procedure masks, wall-mounted alco-
abroad. We found fairly consistent advice on best prac- hol gel dispensers with refills, alcohol gel pumps, and
tices for control of respiratory infections in primary hospital-grade disinfectant wipes. During the 5-week
care5‑10: intervention, the facilitators worked independently but
• give masks to patients with cough and fever; corresponded with the project team daily and attended
• direct patients with cough and fever to clean their scheduled meetings each week to share information and
hands with alcohol-based gel; strategies.
• ensure patients with cough and fever sit at least 1 m
from all others in the waiting area; Outcome measures
• have signs to inform patients about these practices Primary outcome measures were the number and per-
and prepare them to follow the directions; centage of offices that followed the 4 infection-control
• disinfect surfaces that might have been contaminated practices (masks, alcohol gel, spaced seating, and signs)
with respiratory secretions following coughing or both separately and together. A practice was consid-
sneezing (arms of chairs, toys, etc); and ered implemented if it was executed at least once during
• provide masks and alcohol-based hand gel to physi- the observation period. Secondary outcome measures
cians and staff who have contact with patients. included the 2 reported infection-control practices (dis-
infecting potentially contaminated surfaces and use of
Training nurses in outreach facilitation hand-gel dispensers in examining rooms).
Five public health nurses took 2 weeks’ training in out-
reach facilitation and best practices for control of respi- Data analysis
ratory infections. A mnemonic was developed for both Audit forms were coded and entered into SPSS, ver-
the nurses and physicians to summarize best practices: sion 12.0. The quality of data entry was checked by ini-
MASKS (Masks for patients with cough and a fever, tial frequency runs on all data elements to ensure that
Alcohol gel for sanitizing hands, Seat potentially infec- responses were correct and consistent. Frequency tables
tious patients apart from others, “Kleen” by disinfecting were generated and descriptive statistical procedures
hard surfaces, and use Signs). A more detailed descrip- conducted. To compare practice performance over time,
tion and evaluation of the nurses’ training is given in the change in how often preventive measures were used
process evaluation.39 was estimated. Paired t tests were applied to changes
using SAS (version 8.1) to determine whether they were
Before-after audit statistically significant.
Professional nurse auditors gathered data once before
and then 6 weeks after the intervention. Auditors sat for
an hour in physicians’ waiting rooms and noted whether RESULTS
signs informed patients of practices for control of respi-
ratory infections and whether patients who presented Response rate was 22%; 53 of the 242 practices invited
with cough and fever received masks, were instructed agreed to participate in the study. All 53 practices com-
to clean their hands with alcohol-based gel, and were pleted the study, and 95% of physicians within the prac-
instructed to sit at least 1 m away from others. Auditors tices (143/151) agreed to see the nurse facilitators. There
also inquired how often potentially contaminated areas was an average of 4 physicians per practice (range 1 to
were cleaned with disinfectant and whether alcohol- 13). About 40% of physicians were male (Table 1).
based hand gel was used in examining rooms. Auditors Each public health nurse had primary responsibil-
were blinded to the outcome measures and aware only ity for 10 or 11 offices. Each office was visited at least
of data-gathering requirements. twice during the 5-week intervention; 28 offices (55%)
received a third visit, and 7 (13%) received a fourth visit.
Intervention Most meetings were held during the lunch hour.
The intervention began with facilitators providing Statistically significant differences were observed in
feedback to physicians and other practice staff on the all 4 primary outcome measures, both together and sep-
baseline audit of practices for control of respiratory arately (Table 2). Before the intervention, all 4 infection-
infections. Information on evidence-based best prac- control practices were observed in fewer than 4% of
tices and a facilitative “tool kit” was presented directly offices; 6 weeks after the intervention, they were
to physicians or indirectly through them to other staff. observed in more than 50% of offices. The practice most
The tool kit contained colourful signs outlining best frequently followed was posting signs about infection
Research Promoting best practices for control of respiratory infections
control guidelines in waiting areas for patients. Before offering masks to patients with fever and cough. Only
the intervention, 15% of offices followed this prac- 17% of offices did this before the intervention, but about
tice; 6 weeks after the intervention, more than 81% of 66% did so after the intervention.
offices did so. The practice least frequently followed was
Table 1. Characteristics of the 53 participating offices
and 110 physicians: 110 participating physicians DISCUSSION
reported information on certain characteristics before
the intervention; 7 physicians did not respond to either To our knowledge, this is the first study to use a
of the last 2 questions, so means were calculated on the facilitator-based intervention to promote guidelines for
basis of 103 respondents. control of respiratory infections. Few family physicians’
offices followed these guidelines before the intervention.
CHARACTERISTICS NO. WITH CHARACTERISTIC
There was a marked improvement after the intervention
PRACTICES
with almost a 50% increase in adoption of the evidence-
Solo 21 (39.6%) based best practices recommended in the guidelines.
Group (2-4 physicians) 23 (43.4%) Strengths of the study include sufficient statistical
Group (≥5 physicians) 9 (17.0%) power from an adequate sample size and separation of
PHYSICIANS the intervention from the data collection, so that physi-
cians, office staff, and nurse facilitators were blinded to
Male sex 42 (38.2%)
outcomes.
Mean year of graduation 1986
Mean no. of hours of booked 26 .77 h Limitations
appointments per week This was an uncontrolled study. Factors that might
Mean no. of patients seen per 14 .55 lead to overestimation of the intervention’s effective-
half-day ness are the relatively low response rate of 22%, which
Table 2. Results of before-after audit of best practices in control of respiratory infections in family physicians’
offices: P = .0001 (N = 53).
BEFORE THE INTERVENTION AFTER THE INTERVENTION % CHANGE*
N (%) N (%)
PREVENTIVE PRACTICES 95% CI 95% CI 95% CI
PRIMARY MEASURES
Signs about control of 8 (15.4)† 43 (81.1) 67.3
respiratory infections observed 5.2-25.5 70.2-92.0 54.1-80.5
in reception area
Patients with cough or fever
• Given masks or instructed 9 (17.0) 34 (65.4)† 48.1
to wear masks 6.5-27.4 52.0-78.8 34.0-62.1
• Instructed to clean hands 13 (24.5) 42 (79.2) 54.7
with alcohol gel 12.6-36.5 68.0-90.5 38.9-70.5
• Instructed to sit at least 1 m 21 (39.6) 39 (75.0)† 34.6
away from others 26.0-53.2 62.8-87.2 20.1-49.1
Practices that applied all 2 (3.8) 28 (52.8)† 49.0
4 primary measures 0-9.1 38.9-66.7 35.1-63.0
ADDITIONAL MEASURES
Masks available in waiting area 10 (19.2)† 37 (69.8) 51.9
8.2-30.3 57.0-82.6 36.8-67.0
Alcohol gel available in waiting 20 (38.5)† 47 (88.7) 50.0
area 24.8-52.1 79.9-97.5 34.9-65.1
Average number of alcohol 3.2 7.33† 4.2
dispensers in whole office 2.3-4.1 6.1-8.6 3.0-5.3
Contaminated areas cleaned 20 (37.7) 46 (86.8) 49.1
with disinfectant wipes 24.2-51.2 77.4-96.2 32.3-65.8
CI—confidence interval.
*Percent change might not reflect the difference between percentages in the before and after columns exactly due to rounding or to missing data.
†
Valid percentages are used (ie, missing data have been removed).
Promoting best practices for control of respiratory infections Research
suggests that only highly motivated physicians were Competing interests
involved; the release of provincial guidelines, Preventing None declared
Respiratory Illnesses in Community Settings,36 during
the study; and practice staff’s awareness that they were Correspondence to: Dr William Hogg, C.T. Lamont
being observed (Hawthorne effect). Despite efforts to Centre, Élisabeth Bruyère Research Institute, 43 Bruyère
minimize bias, auditors might have inferred the desired St, Ottawa, ON K1N 5C8; telephone 613 562-4262; e-mail
infection-control practices owing to their nursing back- whogg@uottawa.ca
ground. They derived no benefit from the success or fail-
ure of the study, however. References
1. Lee N, Hui D, Wu A, Chan P, Cameron P, Joynt GM, et al. A major outbreak of severe
With a low recruitment rate and without a control acute respiratory syndrome in Hong Kong. N Engl J Med 2003;348(20):1986-94.
2. Booth CM, Matukas LM, Tomlinson GA, Rachlis AR, Rose DB, Dwosh HA, et al.
group, it is impossible to determine the extent to which Clinical features and short-term outcomes of 144 patients with SARS in the greater
the changes were brought about by release of the guide- Toronto area. JAMA 2003;289(21):2801-9.
3. Svoboda T, Henry B, Shulman L, Kennedy E, Rea E, Ng W, et al. Public health mea-
lines or by the intervention or to determine whether sures to control the spread of the severe acute respiratory syndrome during the out-
break in Toronto. N Engl J Med 2004;350(23):2352-61.
the sample of physicians was representative, thus 4. Zambon M. The inexact science of influenza prediction. Lancet 2004;363:582-3.
limiting the generalizability of the findings. Previous 5. Ministry of Health and Long-Term Care. Public health: hand washing. Toronto, Ont:
Ministry of Health and Long-Term Care; 2003. Available from: http://www.health.
research, however, suggests that publishing and dis- gov.on.ca/english/public/program/pubhealth/handwashing/handwashing_
mn.html. Accessed 2006 September 8.
tributing guidelines alone is rarely effective in changing 6. Health Canada. Alcohol for hand hygiene: new comparative studies add to the evidence
base. Ottawa, Ont: Health Canada; 2003. Available from: http://www.phac-aspc.
physicians’ behaviour.11-13 Factors that might have led gc.ca/publicat/ccdr-rmtc/03vol29/dr2901eb.html. Accessed 2006 June 26.
to underestimation of the intervention’s effectiveness 7. Institute for Clinical Evaluative Sciences (ICES). “Out, damned spot!”—hand
hygiene. Informed 2003;9(3):1. Available from: http://www.ices.on.ca/informed/
include the short intervention period of 5 weeks and the periodical/issue/971-vol9issue3Art5.pdf. Accessed 2006 June 26.
8. Centers for Disease Control and Prevention. Respiratory hygiene/cough etiquette
timing of the intervention near the end of the respiratory in healthcare settings. Bethesda Md: Centers for Disease Control and Prevention;
infection outbreak season. 2003. Available from: http://www.cdc.gov/flu/professionals/infectioncontrol/
resphygiene.htm. Accessed 2006 June 26.
9. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings.
...