***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE A performance improvement continuing medical education ( PI CME ) activity was design ed to assist clinicians with accurately identifying and appropriately managing persistent pain in long-term care facility ( LTCF ) residents . DESIGN Volunteer LTCFs participated in a three-stage PI CME model consisting of : 1 ) baseline assessment , 2 ) implementation of practice improvement interventions , and 3 ) re assessment . Expert faculty chose performance measures and interventions for the activity . A champion was design ated ateach LTCF to collect resident charts and enter data into an online data base . SETTING Eight LTCFs located across the United States participated in the activity . PATIENTS Fifty resident charts were r and omly selected by each LTCF champion ( 25 for stage 1 and 25 for stage 3 ) ; a total of 350 charts were review ed . INTERVENTIONS In addition to a toolkit containing numerous performance improvement re sources , an in-service meeting led by an expert faculty member was conducted at each LTCF . OUTCOME MEASURES Stage 3 data were collected 6 weeks after implementation of interventions and compared with stage 1 baseline data to measure change in performance . RESULTS Aggregate data collected from seven LTCFs completing the PI CME activity through stage 3 revealed improvements from baseline in four of five performance measures . CONCLUSIONS This CME activity allowed for collection of data demonstrating performance improvement in persistent pain management . The tools used as part of the intervention ( available at http://www.achlpicme.org/LTC/toolkit ) may help other clinicians enhance their management of LTCF residents with persistent pain Background The diversity of quality improvement interventions ( QIIs ) has impeded the use of evidence review to advance quality improvement activities . An agreed-upon framework for identifying QII articles would facilitate evidence review and consensus around best practice s. Aim To adapt and test evidence review methods for identifying empirical QII evaluations that would be suitable for assessing QII effectiveness , impact or success . Design Literature search with measurement of multilevel inter-rater agreement and review of disagreement . Methods Ten journals ( 2005 - 2007 ) were search ed electronically and the output was screened based on title and abstract . Three pairs of review ers then independently rated 22 articles , r and omly selected from the screened list .  Kappa statistics and percentage agreement were assessed . 12 stakeholders in quality improvement , including QII experts and journal editors , rated and discussed publications about which review ers disagreed . Results The level of agreement among review ers for identifying empirical evaluations of QII development , implementation or results was 73 % ( with a paradoxically low kappa of 0.041 ) . Discussion by raters and stakeholders regarding how to improve agreement focused on three controversial article selection issues : no data on patient health , provider behaviour or process of care outcomes ; no evidence for adaptation of an intervention to a local context ; and a design using only observational methods , as correlational analyses , with no comparison group . Conclusion The level of review er agreement was only moderate . Reliable identification of relevant articles is an initial step in assessing published evidence . Advancement in quality improvement will depend on the theory- and consensus-based development and testing of a generalizable framework for identifying QII evaluations Objective Continuous quality improvement ( CQI ) methods are foundational approaches to improving healthcare delivery . Publications using the term CQI , however , are method ologically heterogeneous , and labels other than CQI are used to signify relevant approaches . St and ards for identifying the use of CQI based on its key method ological features could enable more effective learning across quality improvement ( QI ) efforts . The objective was to identify essential method ological features for recognizing CQI . Design Previous work with a 12-member international expert panel identified reliably abstract ed CQI method ological features . We tested which features met rigorous a priori st and ards as essential features of CQI using a three-phase online modified-Delphi process . Setting Primarily United States and Canada . Participants 119 QI experts r and omly assigned into four on-line panels . Intervention(s ) Participants rated  CQI features and discussed their answers using online , anonymous and asynchronous discussion boards . We analyzed ratings quantitatively and discussion threads qualitatively . Main outcome measure(s ) Panel consensus on definitional CQI features . Results Seventy-nine ( 66 % ) panelists completed the process . Thirty-three completers self-identified as QI research ers , 18 as QI practitioners and 28 as both equally . The features ‘ systematic data guided activities , ’ ‘ design ing with local conditions in mind ’ and ‘ iterative development and testing ’ met a priori st and ards as essential CQI features . Qualitative analyses showed cross-cutting themes focused on differences between QI and CQI . Conclusions We found consensus among a broad group of CQI research ers and practitioners on three features as essential for identifying QI work more specifically as ‘ CQI . ’ All three features are needed as a minimum st and ard for recognizing CQI methods BACKGROUND Challenges exist in implementing evidence -based strategies , reaching high compliance , and achieving desired outcomes . The rapid adoption of a publicly available toolkit featuring routine universal decolonization of intensive care unit ( ICU ) patients may affect catheter-related bloodstream infections . METHODS Implementation of universal decolonization-treatment of all ICU patients with chlorhexidine bathing and nasal mupirocin-used a prerelease version of a publicly available toolkit . Implementation in 136 adult ICUs in 95 acute care hospitals across the United States was supported by planning and deployment tactics coordinated by a central infection prevention team using toolkit re sources , along with coaching calls and engagement of key stakeholders . Operational and process measures derived from a common electronic health record system provided real-time feedback about performance . Healthcare-associated central line-associated bloodstream infections ( CLABSIs ) , using National Healthcare Safety Network surveillance definitions and comparing the preimplementation period of January 2011 through December 2012 to the postimplementation period of July 2013 through February 2014 , were assessed via a Poisson generalized linear mixed model regression for CLABSI events . RESULTS Implementation of universal decolonization was completed within 6 months . The estimated rate of CLABSI decreased by 23.5 % ( 95 % confidence interval , 9.8%-35.1 % ; P = .001 ) . There was no evidence of a trend over time in either the pre- or postimplementation period . Adjusting for seasonality and number of beds did not material ly affect these results . CONCLUSIONS Dissemination of universal decolonization of ICU patients was accomplished quickly in a large community health system and was associated with declines in CLABSI consistent with published clinical trial findings BACKGROUND Both targeted decolonization and universal decolonization of patients in intensive care units ( ICUs ) are c and i date strategies to prevent health care-associated infections , particularly those caused by methicillin-resistant Staphylococcus aureus ( MRSA ) . METHODS We conducted a pragmatic , cluster-r and omized trial . Hospitals were r and omly assigned to one of three strategies , with all adult ICUs in a given hospital assigned to the same strategy . Group 1 implemented MRSA screening and isolation ; group 2 , targeted decolonization ( i.e. , screening , isolation , and decolonization of MRSA carriers ) ; and group 3 , universal decolonization ( i.e. , no screening , and decolonization of all patients ) . Proportional-hazards models were used to assess differences in infection reductions across the study groups , with clustering according to hospital . RESULTS A total of 43 hospitals ( including 74 ICUs and 74,256 patients during the intervention period ) underwent r and omization . In the intervention period versus the baseline period , modeled hazard ratios for MRSA clinical isolates were 0.92 for screening and isolation ( crude rate , 3.2 vs. 3.4 isolates per 1000 days ) , 0.75 for targeted decolonization ( 3.2 vs. 4.3 isolates per 1000 days ) , and 0.63 for universal decolonization ( 2.1 vs. 3.4 isolates per 1000 days ) ( P=0.01 for test of all groups being equal ) . In the intervention versus baseline periods , hazard ratios for bloodstream infection with any pathogen in the three groups were 0.99 ( crude rate , 4.1 vs. 4.2 infections per 1000 days ) , 0.78 ( 3.7 vs. 4.8 infections per 1000 days ) , and 0.56 ( 3.6 vs. 6.1 infections per 1000 days ) , respectively ( P<0.001 for test of all groups being equal ) . Universal decolonization result ed in a significantly greater reduction in the rate of all bloodstream infections than either targeted decolonization or screening and isolation . One bloodstream infection was prevented per 54 patients who underwent decolonization . The reductions in rates of MRSA bloodstream infection were similar to those of all bloodstream infections , but the difference was not significant . Adverse events , which occurred in 7 patients , were mild and related to chlorhexidine . CONCLUSIONS In routine ICU practice , universal decolonization was more effective than targeted decolonization or screening and isolation in reducing rates of MRSA clinical isolates and bloodstream infection from any pathogen . ( Funded by the Agency for Healthcare Research and the Centers for Disease Control and Prevention ; REDUCE MRSA Clinical Trials.gov number , NCT00980980 ) CONTEXT Falls cause injury and death for persons of all ages , but risk of falls increases markedly with age . Hospitalization further increases risk , yet no evidence exists to support short-stay hospital-based fall prevention strategies to reduce patient  falls . OBJECTIVE To investigate whether a fall prevention tool kit ( FPTK ) using health information technology ( HIT ) decreases patient falls in hospitals . DESIGN , SETTING , AND PATIENTS Cluster r and omized study conducted January 1 , 2009 , through June 30 , 2009 , comparing patient fall rates in 4 urban US hospitals in units that received usual care ( 4 units and 5104 patients ) or the intervention ( 4 units and 5160 patients ) . INTERVENTION The FPTK integrated existing communication and workflow patterns into the HIT application . Based on a valid fall risk assessment scale completed by a nurse , the FPTK software tailored fall prevention interventions to address patients ' specific determinants of fall risk . The FPTK produced bed posters composed of brief text with an accompanying icon , patient education h and outs , and plans of care , all communicating patient-specific alerts to key stakeholders . MAIN OUTCOME MEASURES The primary outcome was patient falls per 1000 patient-days adjusted for site and patient care unit . A secondary outcome was fall-related injuries . RESULTS During the 6-month intervention period , the number of patients with falls differed between control ( n = 87 ) and intervention ( n = 67 ) units ( P=.02 ) . Site-adjusted fall rates were significantly higher in control units ( 4.18 [ 95 % confidence interval { CI } , 3.45 - 5.06 ] per 1000 patient-days ) than in intervention units ( 3.15 [ 95 % CI , 2.54 - 3.90 ] per 1000 patient-days ; P = .04 ) . The FPTK was found to be particularly effective with patients aged 65 years or older ( adjusted rate difference , 2.08 [ 95 % CI , 0.61 - 3.56 ] per 1000 patient-days ; P = .003 ) . No significant effect was noted in fall-related injuries . CONCLUSION The use of a fall prevention tool kit in hospital units compared with usual care significantly reduced rate of falls . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00675935 BACKGROUND Since the 2008 inception of universal childhood influenza vaccination , national rates have risen more dramatically among younger children than older children and reported rates across racial/ethnic groups are inconsistent . Interventions may be needed to address age and racial disparities to achieve the recommended childhood influenza vaccination target of 70 % . PURPOSE To evaluate an intervention to increase childhood influenza vaccination  across age and racial groups . METHODS In 2011 - 2012 , a total of 20 primary care practice s treating children were r and omly assigned to the intervention and control arms of a cluster r and omized controlled trial to increase childhood influenza vaccination uptake using a toolkit and other strategies including early delivery of donated vaccine , in-service staff meetings , and publicity . RESULTS The average vaccination differences from pre-intervention to the intervention year were significantly larger in the intervention arm ( n=10 practice s ) than the control arm ( n=10 practice s ) ; for children aged 9 - 18 years ( 11.1 pct pts intervention vs 4.3 pct pts control , p<0.05 ) ; for non-white children ( 16.7 pct pts intervention vs 4.6 pct pts control , p<0.001 ) ; and overall ( 9.9 pct pts intervention vs 4.2 pct pts control , p<0.01 ) . In multi-level modeling that accounted for person- and practice -level variables and the interactions among age , race , and intervention , the likelihood of vaccination increased with younger age group ( 6 - 23 months ) ; white race ; commercial insurance ; the practice 's pre-intervention vaccination rate ; and being in the intervention arm . Estimates of the interaction terms indicated that the intervention increased the likelihood of vaccination 
    Output:
    
Studies generally indicated high satisfaction with toolkits , but the perceived usefulness of individual tools varied .
Conclusions The review documents publicly available toolkits and their components .
High satisfaction with toolkits can be achieved but the usefulness of individual tools may vary .