AMR strains infecting livestock have not demonstrated the capacity to become a hospital pathogen, apart from settings with very vulnerable patients, such as burns centres [83]. However, a large reservoir of pathogenic micro‐organisms with a range of AMR traits increases the risk of developing new resistant strains. An international and national approach was called for and has proven successful in reducing antibiotic use in animal husbandry [81]. On the other hand, travellers and refugees import AMR from countries with higher prevalence [84], so vigilance and an intersectoral approach remain important. Part II 10.5 Bundles of best practices Bundles of best practices to prevent CRBSI and CLABSI have been successful [85]. Evaluating multifaceted practices in a bundle demonstrates that, even when compliance to individual elements is satisfactory, the quality of overall patient care can still be lacking. The increasing attention to patient safety has fostered this more comprehensive approach. In the Michigan Keystone study, an important target was to develop a culture of patient safety, a goal often overlooked in subsequent similar interventions. Parallel to the PROHIBIT intervention study, six hospitals participated in an in‐depth investigation of the main barriers, facilitators, and contextual factors relevant to the success of interventions. Apart from sufficient human and material resources, successful implementation required dedicated change agents who help make the intervention an institutional priority: these personally committed influential individuals and boundary spanners ‐ individuals with multiple roles, traversing institutional boundaries and fostering change ‐ helped overcome resource restrictions and intra‐institutional segregations [86]. The large‐scale adoption of the CRBSI bundle and commitment to the other themes in the Dutch patient safety programme was also facilitated by the introduction of a safety management system [87], that addressed safety management and culture, risk assessments and continuous safety improvements. Bundles of best practices were developed for other HAI as well: SSI [28, 88], VAP [89], CAUTI [90, 91], CDI [92, 93] and other conditions [94‐96]. Frequently included in VAP bundles are daily sedation interruption and assessment of readiness to extubate [97]. A nationwide Dutch survey to evaluate the use of currently recommended practices for preventing CDI and device‐associated HAI, including VAP, revealed that ‘sedation vacation’ was used in 40% of the hospitals [98]. The VAP reduction seen in the Netherlands seems to follow the wide adoption of SDD since the study of de Smet et al. [99]. SDD has now become standard practice in Dutch ICUs [98, 100]. In most other 10 247 General Discussion
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