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As feds pour funding into infection projects, IPs become vital link between research and care
Translating proven prevention to clinical care
Saying preventing health care associated infections (HAIs) is a national priority, the federal Agency for Healthcare Research and Quality (AHRQ) is putting considerable money where its mouth is: $34 million. AHRQ recently allocated the funds to launch 22 HAI prevention and implementation projects across the continuum of care.
In an era of health care reform and scarce resources there is a redoubled sense of urgency to translate proven research into clinical practice. In this new paradigm, infection preventionists are the "linchpin" between research and clinical practice key players in translating science to the patient bedside, says Russell N. Olmsted, MPH, CIC, president of the Association for Professionals in Infection Control and Epidemiology.
"One thing infection preventionists bring to research is that they kind of answer the question of how," says Olmsted, an epidemiologist in Infection Prevention & Control Services, St. Joseph Mercy Health System in Ann Arbor, MI. "Some of the basic research answers the 'what' in terms of strategies that may have benefit in preventing infections. Preventionists take the basic research findings and really translate or implement those. So it is kind of like we are the linchpin. We are connecting that published evidence in the journals to the patient bedside to improve care."
In that regard, one of the key AHRQ projects is national implementation of a Comprehensive Unit-based Safety Program (CUSP) to reduce Central Line-Associated Blood Stream Infections (CLABSIs). AHRQ is pushing for nationwide adoption of a groundbreaking "checklist" approach to preventing CLABSIs in intensive care units, a much heralded program that is often cited as proof that HAIs are preventable rather than inevitable. Originally implemented at Johns Hopkins Hospital and in ICUs throughout Michigan, the program is widely known for using a checklist for proper insertion of central venous lines.1. In addition to the AHRQ project, the protocol is also the focus of a nationwide adoption campaign by APIC. The enthusiasm is well-founded, as the CLABSI prevent protocol recently showed statistically significant reductions in the mortality of older patients.
The ARQ initiative expands the CLABSI prevention program to include all interested hospitals in the U.S., Puerto Rico, and Washington, D.C.
"We are trying to make sure everybody gets on board with what is really a proven approach," says James Cleeman, MD, AHRQ senior medical officer. "This is a good example of trying to accelerate the adoption of an evidence-based method."
The project will also include efforts by some facilities to extend the current CLABSI program to hospital units outside the ICU.
"Consortiums have been created in the various states that include the state health department, the state hospital association and project coordinators so that things are done in an organized way," he says. "They will bring together the hospitals and the state health department and to make sure there is a focus for this partnership in each state."
HHS plan continues to unfold
The AHRQ projects are being funded as part of the Department of Health and Human Services (HHS) Action Plan to prevent HAIs. The HHS collaborative also includes the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services (CMS), and the National Institutes of Health. With the new funding, the agencies are trying to identify and address gaps in HAI prevention, improve antibiotic prescribing practices and delivery, and enhance communication and teamwork among health care providers.
"We think that HAIs are a very important problem," Cleeman says. "The data suggest that they cause in the neighborhood of almost 100,000 deaths a year and more than $30 billion in economic loss. It's a very big problem and we think that there are some proven ways to reduce them."
Asked if such levels of funding for HAI research and implementation projects are expected to continue, Cleeman says, "There are competing priorities all over the health care system. How Congress will act on this is a complicated prediction that I wouldn't dare make. But the reason we are in the business is because we think HAIs are important. The basic AHRQ mission is to improve the delivery of health care. There are agencies that deal at the basic research end of the spectrum, but our mission is more applied and clinical on the implementation end."
The scope of the AHRQ projects and funding level is unprecedented, says William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University in Nashville.
"Infection control has hit the headlines as we all know," he says. "This is a much larger investment in infection prevention and control than we have seen heretofore. There is continuing need to explore and validate a variety of infection control activities that have been proposed. As resources become constrained, obviously we want to do the right thing and the best thing."
In that regard, the AHRQ funding includes a diverse array of research, in addition to trying to improve compliance with things known to work.
"There are many questions about what is the best thing to do and to assess the cost effectiveness of some of the things that are proposed," Schaffner says. "For that we still need guidance. You just have to go to any infection control meeting to understand that there are brisk controversies that go on about the implementation of a variety of practices."
Indeed, when it comes to research and practice, infection control and prevention has been accused at one time or another of opposite extremes: holding fast to "sacred cow" unproven practices or continuing to methodically research areas where accumulated evidence already seems to warrant a given intervention.
"The Cochrane Reviews of research always conclude that there isn't enough evidence or that the evidence is weak [for many infection control practices]," says Elaine Larson, PhD, professor of pharmaceutical and therapeutic Research at the Columbia University School of Nursing in New York City. "But the focus now is not so much on doing new randomized clinical trails, but doing what is called comparative effectiveness research. That, and looking at what is already being done sort of natural experiments to see if when you change practice it results in improved outcomes. That is more a trend now than wanting more rigorous evidence. It is just another way to get evidence."
Universal gloving for C. diff?
For example, one of the ARQ research projects will look at universal gloving, which has become more widely discussed as a possible option since the widespread emergence of Clostridium difficile.
"The standard approach is to glove and gown for patients who have an identified infection and isolation is appropriate," Cleeman says. "This is an attempt to see whether doing it universally putting on gloves and gowns for every patient will reduce the infection rate."
The CDC is particularly interested in the feasibility of universal gloving, in part because C. diff is notoriously difficult to remove by hand washing particularly with the alcohol rubs now ubiquitous in hospitals. There is also the issue of patients who are asymptomatic carriers of C. diff, and thus would not necessarily be in contact isolation.
"When you look for epidemiologic and experimental evidence for C. diff transmission via hands, only gloves have been shown to actually interrupt transmission," says L. Clifford McDonald, MD, FACP, a leading C. diff expert in the CDC's division of healthcare quality promotion. "So that's the point don't let the hands get contaminated in the first place. Whenever you do that of course, you have to prevent [people wearing] the same pair of gloves from room to room and throughout the day, that kind of thing."
In that regard, the ARQ research project will be looking specifically for such unintended consequences, Cleeman says. "When you put on gloves and a gown for every patient you introduce a time issue it takes time and questions arise like would a caregiver, a nurse or a doctor moving from one patient to another find it awkward and cumbersome to put on the gloves and a gown each time?" he says. "Will patient contact by the staff be unintentionally reduced by the requirement to glove and gown?"
The project will include monitoring of compliance, with researchers ultimately trying to determine if infection rates actually are lower in units with universal gloving and gowning. "You can always defeat the intervention, but assuming the intervention is done, does it actually work?" he says. "Does it produce a positive result and are there any negatives?"
The costs of such interventions are a real-world factor that must be part of the equation, Larson adds. "Some interventions that work also end up having other untoward effects and increasing costs the question is what is the cost benefit?" she says. "[But such research] can definitely change practices, just like the research on catheter-related blood stream infections."
The projects will eventually be the subject of reports by AHRQ or published in the medical literature by the researchers. In any case, those shown to be effective will be targeted for broad implementation, Cleeman says.
"That's the rationale for the projects," he says. "They either spread proven approaches or they try to identify an approach that actually works and then thereafter has the promise of being spread wide."
Olmsted points out however, that the speed of adopting new findings in the literature to care delivery can be exceedingly slow. For example, a landmark study published in The Lancet in 1991 demonstrated the superior efficacy of 2% chlorhexidine for skin preparation prior to insertion of central lines. Despite such clear evidence, 14 years later almost a third of hospitals in a national survey were not using the product, he notes. There is more pressure than ever to narrow such gaps between proven research and clinical practice, making infection preventionists key players in the implementation process.
"AHRQ is a key driver of this because one of the areas they are interested in developing in the field is implementation science or translational research," Olmsted says. "What IPs do is take those recommendations and then apply them to their facilities."