Advances in the Prevention and Control of HAIs: Setting the Stage
James B. Battles, James I. Cleeman, Katherine L. Kahn, Daniel A. Weinberg
For over a decade, the Agency for Healthcare Research and Quality (AHRQ) has invested in research and implementation projects to prevent healthcare-associated infections (HAIs) in diverse health care settings. AHRQ's commitment to HAI prevention has been expressed in activities within the Agency and through its funding of contracts and grants. In 2011, AHRQ contracted with IMPAQ International and the RAND Corporation to conduct a synthesis of results from AHRQ-funded HAI projects. The goals of the synthesis are to identify and disseminate the major results and lessons learned from AHRQ-funded research, as well as to identify remaining gaps in the HAI knowledge base. To accomplish these goals, the synthesis draws on information from AHRQ-funded project documents (final reports, peer-reviewed literature, and HAI prevention toolkits), in-depth interviews with project leaders, and materials to be presented in forthcoming supplements of peer-reviewed infection control journals. In addition, this volume, Advances in the Prevention and Control of HAIs, is a key information source for the synthesis project and also serves as a valuable dissemination mechanism for methods-related findings and lessons learned.
This publication continues AHRQ's highly successful Advancesa series and focuses on methodological issues associated with the identification, mitigation, and prevention of HAIs, including challenges encountered in the conduct of the studies and how the challenges were overcome. Complementing this volume's focus on methods, the forthcoming special supplements will present the major results of AHRQ-funded HAI research.
Advances in the Prevention and Control of HAIs presents peer-reviewed manuscripts developed by AHRQ-funded HAI project leaders who have agreed to share important methodological insights and lessons learned. These papers are a form of technology transfer—they provide important methodological details that will facilitate replication of project approaches and results. The information presented here will also assist researchers conducting similar projects because lessons learned are likely to be applicable to other HAI research efforts and to various types of patient safety research and implementation efforts.
Organization: Two Major Categories
The volume includes 19 manuscripts organized into two sections. The first section, Development and Implementation of HAI Prevention Practices, includes 11 papers that discuss methods, challenges, and lessons learned from designing, deploying, and testing HAI prevention practices. The second section, HAI Risk Identification for Quality Improvement, presents eight papers that focus on HAI surveillance methods and the use of data and technology as a means to improve HAI prevention.
The articles represent a diverse set of patient cohorts, practice settings, clinical conditions, and intervention types. They include investigations pertinent to patients and staff in ambulatory surgical centers, outpatient dialysis centers, hospitals, hospital intensive care units, long-term care centers, and assisted living settings. Clinical conditions addressed include infections caused by specific organisms (e.g., methicillin-resistant Staphylococcus aureus [MRSA], Clostridium difficile) as well as specific HAI conditions (e.g., central line-associated bloodstream infection [CLABSI], catheter-associated urinary tract infection [CAUTI]). Despite addressing HAI prevention efforts in different settings and for different HAIs, several themes emerge across these methodological studies.
A prevalent theme is the complexity associated with simultaneously utilizing rigorous, scientifically based methods while assuring flexibility, so that implementation strategies would be responsive to the unique contextual needs of each setting. This complexity has been recognized as one of the key themes of the nascent, but rapidly developing, field of implementation and dissemination science.1-4 It is reassuring that the manuscripts presented in this volume, which specifically address challenges and opportunities in the implementation of HAI research, highlight the same concerns as those raised in the implementation science literature, which spans a wide spectrum of clinical domains.5-7 Papers included in this issue vary with respect to the scientific focus of the work, addressing topics such as antimicrobial stewardship, HAI screening in the postoperative period or in long-term care facilities, development of consensus algorithms for antibiotic use, strategies for systematic data collection from primary care providers in community settings, and engineering risk assessment for patient safety events, such as particular types of HAIs. Despite these differences, each paper expresses the importance of tailoring implementation strategies to account for the clinical, cultural, and information technology contexts of sites.
The papers also highlight the importance of study site stakeholders. Health care leaders often serve an important role as potential champions for successful implementation. Many individuals, including subject-matter experts—such as infection preventionists, infectious disease physicians and pharmacists, primary care providers, and nurses—and a wide spectrum of individuals with varied, but relevant expertise—including environmental specialists, laboratory technicians, clinical coders, and information technologists—played important roles aligning the scientific protocol with the local site's culture, budgetary resources, staffing, and information technology capabilities. Researchers documenting their implementation experiences noted the importance of developing and maintaining strong interpersonal relations to facilitate understanding of contextual factors and to assure open communication as implementation challenges emerge. Multiple investigators demonstrated that resources and staffing of the sites can have a major impact on implementation, functioning either as barriers or facilitators.
Investigators implemented education strategies to address gaps between researchers' clinical goals and the clinical realities of study sites. Researchers were challenged to scale their efforts to reasonably match the fiscal constraints of their sites so that the planned design could reflect the scientific design while recognizing the available (or unavailable) site resources. Cultural characteristics of settings varied substantially. Overall, researchers suggest that interventions in settings in which a champion supports the research work better. Settings in which the culture supported asking questions and discussing challenges tended to be more responsive to the needs of researchers.
Investigators noted that site-specific data capabilities varied tremendously across data sources, including traditional paper-based and electronic health records, claims data, and microbiological data. They responded to these differences by paying considerable attention to access to and quality of their data sources. Investigators conducting multi-site studies identified heterogeneity in data as a challenge. Multiple papers collecting data from diverse health care settings highlight the importance of structuring HAI data in a standardized format that would support meaningful data aggregation and analyses, even when faced with the common problems of unusable and missing data. Although some papers in this volume focus on the application of validation methods to entire data sets, others note only limited validation for data they had received and were expected to use. Overall, much consideration was given to the importance of these data attributes in determining the researchers' ability to maintain the project timeline and budget as planned.
Across all of these manuscripts, a pattern emerges: the studies report on both scientifically grounded findings and practical considerations pertinent to site and patient factors. As a whole, the papers included in this issue consistently highlight the importance of pairing scientific data with qualitative human inputs. Papers feature the need to be flexible and accommodate variations across settings, while also maintaining fidelity in program implementation and systems level intervention.
James B. Battles, PhD, Agency for Healthcare Research and Quality (AHRQ); James I. Cleeman, MD, AHRQ; Katherine L. Kahn, MD, RAND Corporation; and Daniel A. Weinberg, PhD, MBA, IMPAQ International, LLC, served as guest editors of this volume. The statements and conclusions presented in this introduction are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ or the U.S. Department of Health and Human Services.
Address correspondence to: Daniel A. Weinberg, PhD, MBA, IMPAQ International, LLC, 10420 Little Patuxent Parkway, Suite 300, Columbia, MD 21044.
4. Glasgow RE, Vinson C, Chambers D, et al. National Institutes of Health approaches to dissemination and implementation science: current and future directions. Am J Public Health 2012; 102:1274-81. PMID: 22594758.
5. Straus S, Brouwers M, Johnson D, et al. Core competencies in the science and practice of knowledge translation: description of a Canadian strategic training initiative. Implement Sci 2011; 6:127 epub. PMID: 22152223.
6. Kho M, Estey E, DeForge R, Mak L, Bell B: Riding the knowledge translation roundabout: lessons learned from the Canadian institutes of health research summer institute in knowledge translation. Implement Sci 2009, 4:33 epub. PMID: 19523216.
7. Landsverk J, Aarons G, Chambers D, et al. Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Adm Policy Ment Health 2009; 36:24-34. PMID: 19104929.
a. For Advances in Patient Safety: From Research to Implementation; Volumes 1-4 (February 2005), go to www.ahrq.gov/advanceps1. For Advances in Patient Safety: New Directions and Alternative Approaches; Volumes 1-4 (July 2008), go to www.ahrq.gov/advanceps2.