Efeitos de um ciclo de melhoria da qualidade nacional aplicado à estruturação das ações de prevenção das infecções relacionadas à assistência à saúde em hospitais brasileiros

Abstract

Introduction: Healthcare-Associated Infections (HAIs) are a serious care quality related problem throughout the world, but little is known whether the adoption of quality management strategies (QA) can collaborate to reduce these undesired outcomes when implemented externally and nationally. Objective: The objective of this study was to promote the improvement of adherence to the HAI prevention recommendations implemented by the Hospital Infection Control Committees (CCIH) of Brazilian hospitals. Methodology: The National Health Surveillance Agency (ANVISA), responsible for risk control in the Brazilian health services, held an improved nationwide quality cycle using a quasi-experimental before-after design. After setting 11 quality criteria based on evidence for the prevention of HAIs, a national evaluation was conducted (March,2015) addressed to all Brazilian hospitals with adult, pediatric or neonatal (N = 1,869) Intensive Care Units (ICU). Using the information from this assessment an external national intervention was planned and implemented (April,2015 to February,2016), in order to improve adherence to the assessed quality criteria. After the intervention, a national revaluation was performed (03/01 to 04/15//2016), to measure the effects of the intervention and identifying the remaining opportunities for improvement that could guide the continuity of national actions. The point estimate is calculated and confidence interval (95%) of the criteria in each evaluation, absolute and relative improvement after the intervention and the statistical significance of improvement with one-sided Z test. Results: 563 Brazilian hospitals with ICU beds participated in the 1st assessment (30.1% response, total of 86,837 beds), 681 hospitals participated in the second assessment (36.4% response, the sum of 101,231 beds) and 388 hospitals participated in both assessments. When comparing the results of the two evaluations, it was demonstrated the effectiveness of the improvement cycle, as there was significant improvement (p <0.05) in 10 of the 11 quality criteria assessed. In the assessment of the compound indicator: Quality of prevention of HAIs, constructed from the pooled analysis of all 11 criteria, there was significant improvement: 82.4% to 88.3%, p = 0.001 (relative improvement average 33.5%). The overall strengths of hospitals, revealed the criteria with greater compliance after the intervention, were that "the ICUs had structural conditions and quality of supplies for hand hygiene (HM) of health professionals" (97.9% vs 100%; p = 0.001) as well as "owned implemented protocol for HM" (92.9% vs. 96.9%; p = 0.001); and that "health services performed notification of IRAS regularly, based on national diagnostic criteria" (91.8% vs 92.4%; p = 0.407). On the other hand, the main weaknesses highlighted by fewer compliances are "monitoring of adherence to hand hygiene by professionals" (60.7% vs 70%, p = 0.001); "existence of institutional protocol deployed to the targeted use of antimicrobial agents" (73.2% vs 80.7%; p = 0.001) and "professionals of CCIHs promote strategies to increase the participation of patients / caregivers / family members of ICU in prevention and control of HAI "(76.6 %% vs. 82.8%; p = 0.004). Conclusions: The quality improvement cycle was helpful to identify priorities for action at the national level as much as in the states and the Federal District and to guide the establishment of an intervention project for quality and patient safety based on an evaluation process. In addition, this project demonstrated that it is possible to achieve real improvement nationwide of HAI prevention actions through the use of QA strategies.