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The researchers acknowledged that sampling data from only one hospital and with a relatively small sample size of 250 patients were limitations of the study that could impact the generalizability and reliability of the results. To help address these limitations, the researchers took several steps in the design, data collection, and analysis phases of the project.

In the study design phase, the researchers chose the hospital purposely as it was a large, urban, academic medical center that served a racially, ethnically, and economically diverse patient population from both the local community as well as patient referrals from other areas. This helped make the sample more representative of the broader population beyond just the local community served by that single hospital. The researchers only included patients across all departments of the hospital rather than focusing on specific diagnosis or treatment areas to get a broad cross-section of overall hospital patients.

Regarding sample size, while 250 patients was not a massive sample, it was a sufficient size to conduct statistical analyses and identify meaningful trends according to power calculations conducted during the study design. Also, to supplement the quantitative survey data from patients, the researchers conducted in-depth qualitative interviews with 20 patients to gain deeper insights into experiences that larger-scale surveys alone may miss. Interviewing a subset of the sample allowed for a mixed-methods approach that provided richer contextual understanding to support the quantitative findings.

During data collection, the researchers took efforts to maximize the response rate and reduce non-response bias that are risks with smaller samples. For the patient surveys, research assistants were present on various hospital units at varying times of day to approach all eligible patients during their stays, rather than relying on mail-back surveys. Monetary incentives were also provided to encourage participation. The quantitative survey included demographic questions so the researchers could analyze response patterns and identify any subgroups that may have been underrepresented to help address missing data issues.

For analysis and reporting of results, the researchers were transparent about the limitations of sampling from a single site and small sample size. They did not overgeneralize or overstate the applicability of findings but rather framed results asexploratory and in need of replication. Statistical significance was set at a more stringent level of p<0.01 rather than the typical p<0.05 to increase confidence given the moderate sample. Qualitative interview data was used to provide context and nuanced explanation for quantitative results rather than being reported separately. The researchers also performed several supplementary analytical tests to evaluate potential sampling bias. They compared their participant demographics to hospital patient demographics overall as an indicator of representativeness. Response patterns by demographic group were examined for non-response bias. They randomly split the sample in half and ran parallel analyses on each half to verify consistency of identified associations and trends, rather than assuming results would replicate with an independent sample. In their write-up and discussion of limitations, the researchers clearly acknowledged the constraints of the single-site setting and sample size. They argued their intentional sampling approach, mixed-methods design, response maximization efforts, more rigorous analysis, and supplementary tests provided meaningful initial insights with results that lay the necessary groundwork for future replication studies with larger, multi-site samples before making conclusive generalizations. The transparency around limitations and implications for applicability of findings model best practices for rigorously addressing challenges inherent to pilot and feasibility studies. Through careful attention in their methodology and analysis, the researchers took important steps to offset the acknowledged issues that could arise from their relatively small, single-site sample. Their comprehensive approach set the stage to begin exploring meaningful trends while also recognizing the need for future replication. The study provides an example of how initial feasibility research can be conducted and reported responsibly despite inherent sampling constraints.


Hospital acquired infections, also known as healthcare-associated infections (HAIs), are a significant issue that impacts patient outcomes and increases healthcare costs. Implementing quality improvement projects focused on evidence-based practices to reduce HAIs has been shown to be an effective way for hospitals and healthcare workers to enhance patient safety. Here are some examples of successful capstone projects that have made a meaningful impact in reducing various types of hospital acquired infections:

One notable project took place at an academic medical center and focused on reducing central line-associated bloodstream infections (CLABSI) in the intensive care unit (ICU). CLABSIs occur when bacteria or viruses enter the bloodstream through a central line catheter. This project used the Model for Improvement framework to test changes. Interventions implemented included adopting a maximal sterile barrier during central line insertion, using chlorhexidine for skin antisepsis, and focusing on prompt removal of unnecessary lines. Compliance with best practices was tracked and deficiencies were addressed. After 12 months, the medical ICU saw a 65% reduction in CLABSI rates from a baseline of 3.7 infections per 1,000 line days to 1.3 infections. This reduction equated to 17 avoided infections and an estimated cost savings of $514,000 for the hospital.

Another successful capstone quality improvement project centered around reducing catheter-associated urinary tract infections (CAUTIs) in a surgical ICU. CAUTIs develop when bacteria enter the urinary tract through a catheter. The project team established evidence-based practices for catheter insertion and maintenance, including use of aseptic technique and sterile equipment during insertion, securing catheters properly after insertion, and only using catheters when necessary as indicated by daily reviews. Educational programming was provided to nurses. Visual aids served as daily reminders. Within 6 months of implementing the changes, monthly CAUTI rates dropped from a baseline of 2.6 per 1,000 catheter days to zero infections, representing a 100% reduction. An estimated 20 avoided infections resulted in cost savings of $400,000 for the hospital.

A capstone project at a community hospital targeted reducing ventilator-associated pneumonia (VAP) in its medical ICU. VAP occurs when bacteria enter the lungs through an endotracheal breathing tube in patients on mechanical ventilation. The core project team developed a multidisciplinary VAP bundle checklist and instituted “VAP champions” – nurses trained to serve as expert resources on VAP prevention. Education focused on maintaining the head of the bed at 30 degrees or higher, oral care with chlorhexidine, and ensuring peptic ulcer disease prophylaxis. Process measures showed near perfect compliance with the bundle elements. After 6 months, the VAP rate dropped from a baseline of 3.3 per 1,000 ventilator days to 1.7, representing almost a 50% reduction. An estimated 10 VAPs were prevented, saving the hospital approximately $300,000.

Another successful quality improvement capstone took place at a large tertiary care hospital and focused on reducing surgical site infections (SSIs) specifically after coronary artery bypass graft (CABG) surgery. SSIs occur when bacteria enter through an incision made during surgery. Best practices targeted in the project included pre-operative chlorhexidine showers or wipes for patients, appropriate antibiotic prophylaxis timing and selection, intra-operative normothermia maintenance, glucose control, wound protection, and smoking cessation support. educational in-services and visual prompts reinforced the changes. Over 18 months, compliance with all SSI prevention practices improved significantly from a baseline average of 65% to 95%. Simultaneously, the CABG SSI rate declined by 50%, from 2.5% of patients to 1.2%. This reduction meant 19 fewer infections annually and an estimated cost avoidance exceeding $500,000.

As demonstrated through these illustrative capstone quality improvement projects, multi-pronged, evidence-based approaches focused on consistent adherence to best practices can meaningfully reduce hospital acquired infection rates. Sustained reductions in CLABSI, CAUTI, VAP, and SSIs each lead to improved patient outcomes and substantial cost savings. A culture of safety, staff education, visual reminders, consistent leadership support, and multidisciplinary involvement all contributed to success. With applied efforts to optimize evidence-based care, hospitals can enhance quality and safety for patients through effective measures targeting the reduction of preventable HAIs.