Implementation of daily objectives for the reduction of multidrug-resistant infections in an intensive care unit

Abstract

Objective

To evaluate the impact of implementing a daily target sheet on meeting quality indicators and reducing healthcare-associated infections caused by multidrug-resistant organisms in an adult intensive care unit.

Results

Improvement was observed in compliance with the evaluated indicators: taking cultures prior to the start of antibiotics, daily awakening test, use of propofol maximum 72 h, and use of daily objective sheet (P<0.05), for these indicators. Multidrug-resistant infections decreased from 10 to 2 cases, with a reduction in the healthcare-associated infections rate from 35.1 to 28.4 per 100 discharges (P<0.05).

Introduction

During the first three months of 2021, the Adult Intensive Care Unit (ICU) of the General Hospital of León from Institute of Public Health from Guanajuato State, (IPHGS), experienced an unusual increase in healthcare-associated infections (HAI) caused by multidrug-resistant (MDR) bacteria, with a total of 14 cases in February and March. The main etiology were 11 cases of MDR Acinetobacter baumannii and 2 cases of MDR Klebsiella pneumoniae; this led to an increase in mortality, length of stay in the ICU, days of mechanical ventilation, and associated economic costs [1].

Pronovost et al., [2] and Khorfan [3], reported implementing a daily goal sheet can impact the reduction of this problem while improving the quality and safety of healthcare provided. Pronovost et al. documented that, with the use of daily goals and a multidisciplinary round, goal understanding improved by up to 95% and length of stay in the ICU decreased by up to 50% [2].

There are some authors reporting the benefits of use a daily checklist in ICU for best care of patients [4–7].

Palomar-Martínez et al., [8] reported the effectiveness of these strategies in reducing bacteremia, ventilator-associated pneumonia, and catheter-related infections, particularly when implemented as part of structured national programs.

However, the specific association between the use of daily goals and the reduction of MDR infections has been scarcely studied, which motivated the development of this work in the context of an ICU from a secondary-level hospital in León, México. The main objective was to analyze whether the implementation of daily targets as a quality and safety criterion in medical care can reduce MDR infections in an intensive care unit.

Main text

The study was conducted in the ICU of the General Hospital of León, Guanajuato, Mexico, a secondary-level hospital with 260 beds. The ICU has 11 beds converted into an infectious disease unit in the context of the COVID-19 pandemic and an intermediate care unit with 7 beds.

Admission criteria included: suspected or confirmed infection, mechanical ventilation and sedation, APACHE II score greater than 8, and assessment using the SOFA score [9, 10].

The participating staff consisted of 16 attending physicians, 9 critical care residents, 7 rotating residents, and 27 nurses. After the initial assessment, they received 10 h of training on the indicators and the correct use of the daily target sheet. Each cubicle was equipped with individual isolation, positive pressure, and high efficiency particulate arresting filters [11].

An improvement cycle was implemented using concurrent evaluation, convenience sampling, cross-assessment, and shadowing in two phases: the first evaluation in April–May 2021 and the second in June–July 2021. The participants were blind to being evaluated. All adult patients admitted to the infectious disease ICU with an APACHE II score greater than 8, suspected or confirmed infection, and a need for sedation and mechanical ventilation for more than 72 h were included. In the first phase, 73 morning rounds were evaluated in 41 patients; in the second, 68 rounds were evaluated in 34 patients.

Seven quality indicators were selected based on the 2017 Spanish Society of Intensive Medicine and Coronary Units recommendations [12]: (a) proper handwashing technique using the World Health Organization five moments and the 11-step technique; (b) obtaining cultures before initiating antibiotics; (c) empirical antibiotic therapy directed at the site of infection; (d) antibiotic de-escalation guided by culture results; (e) daily awakening test; (f) use of propofol for a maximum of 72 continuous hours; and (g) use of a daily goal sheet during ward rounds. The reliability of the criteria was assessed through a pilot study with a Kappa index greater than 0.6. Data collection was performed using shadow study by a second-year resident physician and a nurse from the morning shift, both of whom had received prior training.

Statistical analysis used Z-tests for two proportions and P-values, with STATA 13.0 (Stata Corp., College Station, TX, USA).

In the first evaluation (April–May 2021), 73 ward rounds were analyzed out of a total of 104 performed; 31 (29.81%) were excluded because the patient did not have invasive mechanical ventilation. The results of compliance with the 7 indicators in both evaluations are shown in Table 1; statistically significant differences were found for culture prior to antibiotics, daily wake-up test, maximum propofol use: 72 h and use of daily goal sheet (P<0.05).

Table 1.

Comparison of first vs. second evaluation of visits from health personnel.

Source: files of the research

Criteria	First evaluation Visit from health personnel (n = 73) Non-compliance		Second evaluation Visit from health personnel (n = 68) Non-compliance		Z for two proportions	P-value
	n	(%)	n	(%)
Handwashing technique	6	8.21	2	2.94	1.35	0.18
Culture prior to antibiotics	29	39.73	9	13.24	3.54	0.0004
Empirical antibiotic targeted to the site of infection	2	2.74	2	2.94	−0.07	0.94
Guided de-escalation of antibiotics with cultures	14	19.18	13	19.12	0.0.009	0.99
Daily wake-up test	54	73.97	19	27.94	5.47	0.00001
Maximum propofol use: 72 h	39	53.42	21	30.88	2.71	0.007
Use of daily goal sheet	64	87.67	6	8.82	9.36	0.00001

During the same period, the Hospital Epidemiological Surveillance Unit (UVEH) reported a total of 24 HAI: 10 cases in April, and 14 in May, with a percentage of 35.1% discharges. Of these, 10 infections were caused by MDR pathogens (42.00%), 7 cases of MDR Acinetobacter baumannii and 3 cases of MDR Klebsiella pneumoniae.

In the second evaluation, UVEH reported 20 HAI cases: 8 in June and 12 in July, with a discharge rate of 28.4%, representing a 6.65% difference compared to the initial evaluation. The proportion of MDR infections decreased from 10 to 2 cases (42.00% vs. 10.00%; Z = 8.05. P<0.001) of MDR Klebsiella pneumoniae;in the second evaluation there is not any case of Acinetobacter baumannii.

Table 1 presents the comparison of non-compliance rates across seven quality indicators between the first and second evaluations. Overall, the implementation of quality indicators resulted in statistically significant improvements in four of the seven criteria assessed.

The most substantial improvement was observed in the daily goal sheet indicator, which showed a reduction in non-compliance from 87.67% to 8.82% (Z = 9.36; p < 0.00001), representing a decrease of nearly 79% points. Similarly, the daily awakening test demonstrated a significant reduction in non-compliance from 73.97% to 27.94% (Z = 5.47; p < 0.00001), reflecting a 46-point improvement. Maximum propofol use within 72 h decreased from 53.42% to 30.88% (Z = 2.71; p = 0.007), and culture prior to antibiotic initiation improved from 39.73% to 13.24% (Z = 3.54; p = 0.0004) (Table 1). The use of propofol was continuous IV infusion does not exceed 72 h.

In contrast, three indicators did not reach statistical significance between evaluation periods. Handwashing technique showed a modest reduction in non-compliance (8.21% to 2.94%; Z = 1.35; p = 0.18), likely reflecting an already low baseline non-compliance rate that limited the statistical power to detect further change. Empirical antibiotic therapy targeted to the site of infection remained virtually unchanged (2.74% vs. 2.94%; Z = − 0.07; p = 0.94), consistent with a near-ceiling compliance level at baseline. Notably, culture-guided de-escalation showed no meaningful improvement between evaluations (19.18% vs. 19.12%; Z = 0.009; p = 0.99), suggesting the presence of persistent barriers whether educational, structural, or organizational that were not adequately addressed by the intervention and warrant targeted strategies in future implementation efforts (Table 1).

Taken together, these findings indicate that the quality improvement intervention had a differential impact across indicators, achieving the greatest gains in those with the highest baseline non-compliance rates, while revealing specific areas requiring further intervention to achieve sustained and comprehensive quality of care in the ICU setting.

The Pareto chart developed before and after the intervention confirmed an improvement in compliance with quality and safety indicators exceeding 50% (Fig. 1). Qualitatively, following the intervention, a notable improvement in team dynamics and more active participation from all staff during multidisciplinary rounds were observed. The routine use of the daily objectives sheet as a checklist structured the morning rounds, facilitated communication among team members, and promoted simultaneous adherence to several quality indicators.

Fig. 1.

Pareto chart for the first and second evaluation. A First evaluation. B Second evaluation Source: files of the research

Limitations

The main limitations of the study are the small sample size, obtained over a short period, and the variability in patient conditions related to the COVID-19 pandemic, which explains the smaller-than-expected proportion in the HAI. Therefore, the results are not entirely generalized, although the study can be replicated using the same universal quality indicators for ICU. Studies with longer follow-up periods and multicenter designs are recommended to confirm the long-term association between the use of daily targets and the reduction of MDR.

Strength

If the procedure is repeated more often, it is likely that the proportion of healthcare-associated infections in the ICU will decrease even further, and not only MDR infections, since the quality indicators are designed for this purpose, as well as the implementation of preventive packages contained in daily objective checklists.

Abbreviations

APACHE

Acute physiology and chronic health evaluation

HAI

Infecciones Asociadas a la Atención de la Salud

HEPA

High efficiency particulate arresting

ICU

Intensive care unit

IPHGS

Institute of Public Health from Guanajuato State

MDR

Multidrug resistant

SOFA

Sequential Organ Failure Assessment

UVEH

Unidad de Vigilancia Epidemiológica Hospitalaria

Author contributions

AHR-M: conceptualization, study design, data collection, statistical analysis, and drafting of the original manuscript. BMF-P: supervision, critical review of intellectual content, and academic guidance. BV-M: methodological advice and critical review of content. NP-R wrote the first draft in English and adapted it for the requirements from scientific article. All authors read and approved the final version of the manuscript.

Funding

This study did not receive external funding. The resources used came from the ordinary budget of the Intensive Care Unit of the General Hospital of León, IPHGS.

Data availability

The data supporting the findings of this study are available upon reasonable request to the corresponding author. The data are not available in public repositories due to institutional confidentiality restrictions.

Declarations

Ethics approval and consent to participate

The development of the project was performed under Helsinki Declaration. This study involves the implementation of an improvement cycle with interventions aimed at enhancing the care process and staff training. Therefore, formal approval was requested from the Research Ethics Committee of the General Hospital of León and the Committee approved it with registration PIHGL-CEIS-044-2025. All patients have signed informed consent for admission and procedures from their legal representative.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.