The national response for preventing healthcare-associated infections: research and adoption of prevention practices.

ORIGINAL ARTICLE

The National Response for Preventing Healthcare–associated Infections Research and Adoption of Prevention Practices Katherine L. Kahn, MD,*w Peter Mendel, PhD,* Kristin J. Leuschner, PhD,* Liisa Hiatt, MS,* Elizabeth M. Gall, MHS,z Sari Siegel, PhD,z and Daniel A. Weinberg, PhDz

Background: Healthcare–associated infections (HAIs) have long been the subject of research and prevention practice. When findings show potential to significantly impact outcomes, clinicians, policymakers, safety experts, and stakeholders seek to bridge the gap between research and practice by identifying mechanisms and assigning responsibility for translating research to practice. Objectives: This paper describes progress and challenges in HAI research and prevention practices, as explained through an examination of Health and Human Services (HHS) Action Plan’s goals, inputs, and implementation in each area. Research Design: We used the Context-Input-Process-Product evaluation model, together with an HAI prevention system framework, to assess the transformative processes associated with HAI research and adoption of prevention practices. Results: Since the introduction of the Action Plan, HHS has made substantial progress in prioritizing research projects, translating findings from those projects into practice, and designing and implementing research projects in multisite practice settings. Research has emphasized the basic science and epidemiology of HAIs, the identification of gaps in research, and implementation science. The basic, epidemiological, and implementation science communities have joined forces to better define mechanisms and responsibilities for translating HAI research into practice. Challenges include the ongoing need for better evidence about intervention effectiveness, the growing implementation burden on healthcare providers and organizations, and challenges implementing certain practices.

From the *RAND Corporation, Santa Monica; wDavid Geffen School of Medicine at UCLA, Los Angeles, CA; and zIMPAQ International, Columbia, MD. Supported by Health and Human Services Contract No. HHSA290200710071T Task Order No. 7, with funding provided by the Agency for Healthcare Research and Quality, the Office the Assistant Secretary for Health and the Centers for Disease Control and Prevention. The authors declare no conflict of interest. Reprints: Katherine L. Kahn, MD, RAND Corporation, 1776 Main Street, Santa Monica, CA 90407. E-mail: Kahn @rand.org. Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www.lww-medical care.com. Copyright r 2014 by Lippincott Williams & Wilkins ISSN: 0025-7079/14/5202-0S33

Medical Care

Volume 52, Number 2 Suppl 1, February 2014

Conclusions: Although these HAI research and prevention practice activities are complex spanning multiple system functions and properties, HHS is making progress so that the right methods for addressing complex HAI problems at the interface of patient safety and clinical practice can emerge. Key Words: healthcare–associated infections (HAIs), HAI research, adoption of HAI prevention practices (Med Care 2014;52: S33–S45)

H

ealth care–associated infections (HAIs) have long been the subject of research and prevention practice. When research provides evidence that a particular intervention or practice has the potential to improve HAI outcomes, clinicians, policymakers, safety experts, and stakeholders seek to identify mechanisms and assign responsibility for translating research to practice. However, the science of translating research to practice is still evolving.1–4 Translation and implementation sciences have been the subject of much discussion in recent years, and have been the driving force behind a major reorganization of funding for American’s academic medical centers,5–7 and for multiple governmental agencies and nongovernmental organizations.8,9 To develop a coordinated approach, the US Health and Human Services (HHS) introduced its National Action Plan to Eliminate HAIs in 2009.10,11 The Action Plan identified the challenge of aligning research priorities with the adoption of prevention practices across federal and state agencies and down to the point of care. In this paper, we assess efforts put forth by HHS’s Action Plan to address 2 key functions of the HAI prevention system framework: Knowledge Development and HAI Prevention Practice Adoption.12 Knowledge development pertains to the full range of HAI-related research, from basic science and epidemiology, to development of prevention practice interventions and implementation science.13 HAI prevention practice adoption refers to the implementation, use, and sustainability of HAI prevention practices in healthcare and community settings. The 2 functions are closely related as a critical predictor of successful adoption of HAI prevention practices is a well-defined evidence base. This paper describes progress and challenges in both of these functions, as explained through an examination of goals, inputs, and implementation www.lww-medicalcare.com |

S33

Medical Care

Kahn et al

in each area.12 In addition, this paper examines links between knowledge development and adoption of prevention practices, and the relationship between the 2 in the context of HAI prevention. We also examine the role of other system functions (infrastructure development14 and data and monitoring15) in supporting the link between research and adoption of prevention practices, and the role of system properties (eg, coordination and alignment, accountability and incentives, stakeholder engagement, resources) in enabling and linking functions to improve system performance and outcomes.

METHODS This evaluation used the Context-Input-Process-Product (CIPP) model,16 together with the HAI prevention system framework described by Kahn and colleagues12,13 in this issue. There are 4 core components of CIPP as used in our research: (1) the Context in which HAIs and efforts to mitigate them developed; (2) the Inputs and decisions made about how to leverage resources, infrastructures, and relationships to select the set of activities for implementation; (3) Processes of implementation for selected activities; and (4) Products and outcomes. In this article, we focus in particular on the first 3 components of the model: context, inputs, and process. Outcomes defined as trends in HAI rates and capacity for HAI interventions are discussed later in this issue. To provide a more-focused categorization with the components of the CIPP model and to facilitate understanding of the data collected for the evaluation, we also developed a system framework specific to HAI prevention. This framework includes 4 system functions, which enable the healthcare system to prevent and mitigate HAIs (Infrastructure Development, HAI Data and Monitoring, Knowledge Development, and Adoption of HAI Prevention Practices), and 5 system properties, which affect the Action Plan’s ability to foster change and improvement in the system functions (Prioritization, Coordination and Alignment, Accountability and Incentives, Stakeholder Engagement, Resources). To inform the CIPP evaluation, we implemented multiple methodologies, including ongoing review and assessment of articles and other documents, observations of interagency meetings and national stakeholder conferences, semistructured interviews with federal and other governmental and nongovernmental stakeholders. A supplemental Online Methods Appendix (Supplemental Digital Content 1, http://links.lww.com/MLR/A669) provides further information on the methods used.

RESULTS Context for HHS’s Action Plan Addressing Research and Prevention Practice Adoption There was a long history—and rich context—of research and prevention practices related to HAIs from which Action Plan leaders could draw. Over the several decades before the Action Plan, multiple agencies and organizations leveraged their resources in efforts to stem the tide of the HAI epidemic. In 1976, to support adoption of evidence-

S34 | www.lww-medicalcare.com


based practices, the Joint Commission on Accreditation of Healthcare Organizations added the requirement for infection surveillance and control programs as a hospital accreditation standard.17 In 1978, the Healthcare Infection Control Practices Advisory Committee was endorsed as “an advisory committee on nosocomial infection control practice” to ensure that “all nosocomial infection control practices and policies should be based on good scientific data adapted to the unique needs of each hospital.”18 Center for Disease Control (CDC) revised its methodology for targeted surveillance with the National Nosocomial Infections Surveillance System, refined definitions for infections,19,20 introduced advanced methods for risk adjusting infection rates, and systematically fed infection rates back to participating hospitals.21 CDC noted that hospitals that monitored HAIs demonstrated a marked reduction in bloodstream infection (BSI) rates in intensive care units (ICUs).22 The Society for Healthcare Epidemiology held 2 major consensus panels addressing, respectively, the inpatient and out-of-hospital requirements for infrastructure and essential activities of infection control and epidemiology.23,24 Subsequently, HICPAC implemented its meticulous process of developing evidence-based guidelines for infection control, and multiple evidence-based guidelines for the prevention of HAIs were published with support by the national epidemiological and infection control communities.25–33 In 2008, a task force of leading experts from Society for Healthcare Epidemiology and the Infectious Disease Society of America compiled a compendium of HAI prevention strategies for use in acute care hospitals.34 Another critical element relevant to the context for research and prevention practice adoption was the evolving patient safety movement. Although advances in infection control were progressing, the national patient safety movement was also developing and emphasizing the need to distinguish practices based upon sufficient high-quality evidence. Methods emerged to support evidence-based practices, including advances in matching study designs with research questions, systematic evaluation of the quality of research literature using synthesis and summary techniques, quantitative evaluation of the strength of evidence to support valued outcomes, and explicit identification of gaps in evidence.35–37 In response to the call for improved patient safety, the IOM recommended the prevention of HAIs as one of 20 priority areas on which the US Department of Health and Human Services (HHS) and other public and private sectors should focus.38 The Leapfrog Group,8 Consumer Reports,39 and the Institute for Healthcare Improvement9 developed recommendations and/or tools for how professionals and consumers could contribute to HAI prevention.40 The Agency for Healthcare Research and Quality (AHRQ), the federal agency with the largest budget for patient safety, developed a major focus on HAIs41 and the CDC’s Division of Healtchare Quality Promotion supplemented its longstanding focus on epidemiology and HAI prevention with renewed efforts to engage states and local stakeholders in HAI prevention.42 AHRQ requested that the National Quality Forum use a consensus process to define best practices, and r

2014 Lippincott Williams & Wilkins

Medical Care


commissioned an Evidence-based Practice Center to evaluate safety practices according to evidence.43 In 2001, the first Critical Analysis of Patient Safety Practices was published, presenting 11 practices, including 4 related to HAIs, with the strongest supporting evidence for interventions that decrease the risk for hospitalization, critical care, or surgery.44 The report noted evidence gaps for system-level interventions, patient safety practices beyond hospital settings, and potential or actual contributions from engineering, information technology, and management—3 disciplines with particular relevance to improving HAI prevention practices. A subsequent AHRQ Evidence Report specifically focused on the effects of quality-improvement strategies on promoting adherence to interventions to reduce HAIs.45 This report noted that, overall, the methodological quality of studies was poor, such that authors were unable to reach firm conclusions about actionable quality-improvement strategies to prevent HAIs. They suggested an urgent need for studies of qualityimprovement strategies for HAI prevention.44 As this brief history indicates, there was a solid foundation of research and prevention practices upon which Action Plan leaders could build. However, there were concerns that agencies might be funding some duplicative studies and, in the area of prevention, that there were too many recommended practices. In 2008 the Government Accounting Office criticized HHS’s approach to the HAI epidemic, citing among other findings, >1200 Centers for Disease Prevention and Control (CDC)-recommended practices for preventing HAIs, with >500 being “strongly recommended” for implementation.46 Thus, a key task for the Action Plan’s developers was to determine which existing research and activities to prioritize, which to deemphasize, and where new efforts were needed. In the following sections, we discuss results from the evaluation of Action Plan goals, inputs, and implementation processes, first, for research, and then for prevention practice adoption.

Research Goals The Action Plan’s selection of goals and objectives was responsive to the need to better coordinate research efforts and prioritize research topics that would address knowledge gaps. In the initial release of the Action Plan in 2009, the Research Working Group of the Steering Committee identified several objectives for the work group: coordination and prioritization of research efforts to reduce HAIs nationwide, design of a plan and metrics for evaluating HAI progress within the research domain, and serving as a contact point to communicate to stakeholders so that HHS’s efforts would be coordinated and linked to a broader national coalition. The Research Working Group identified 4 core research domains: the basic science underlying HAIs, the epidemiology of HAIs, the investigation of infection control interventions, and implementation science for interventions to prevent HAIs. In 2012, the Research Working Group also emphasized the value across these domains of research of the role of data and monitoring and technology in promoting HAI prevention. The Research Working Grop noted the importance ofincentives for changing uptake and imr


Indicators of Overuse of Healthcare Procedures

plementation. It also added new implementation science goals emphasizing the importance of linking “discovery science” with practice-based research conducted in the context of ongoing clinical care.47,48 Finally, the 2012 Action Plan introduced research specifically related to ambulatory surgical centers (ASCs) and influenza vaccinations among healthcare personnel, consistent with the focus on expanding research to venues beyond hospitals (Table 1). Table 2 shows the mechanisms by which these 4 domains are likely to improve HAI outcomes (the “product” or final “P” in the CIPP model). The Action Plan’s research goals focused on 4 core domains; this choice was responsive to mounting evidence concerning the importance of expertise in these distinct research areas, whereas the emphasis on linkages across these 4 core domains was responsive to mounting evidence about the importance of translation from basic to population science.49 The expanded focus from the hospital to other venues highlighted the growing importance of transitions in care settings for the spread of multidrugresistant organisms and HAIs.

Research Inputs and Implementation Processes Key research inputs (the “I” in the CIPP model) included individual research projects funded by the core agencies involved in the Action Plan, as well as a broader HAI research agenda. Implementation processes (the first “P” in CIPP) focused on coordination and prioritization of research efforts, development of metrics to track research progress, and stakeholder engagement with the Action Plan. We discuss these issues next.

Decisions to Align the Research Agenda With Action Plan’s Goals The establishment of an interagency Research Working Group was a useful tool for enhancing knowledge transfer, sharing content expertise, and developing a research agenda that could be shared across the 4 research domains and also across diverse stakeholders. The Research Working Group recognized the substantial contributions to HAI research of 4 federal agencies; these studies were important inputs to the Action Plan. At present, NIH is leading biomedical research to prevent, diagnose, and treat diseases; CDC is focused on population health and the role of statebased and community-based interventions to improve health; AHRQ is focused on long-term and system-wide improvement of healthcare safety, quality, and effectiveness. The Center for Medicare Services (CMS) is leading the effort toward value-based purchasing, and the Office of the Assistant Secretary for Health (OASH) is coordinating Action Plan efforts. These agencies have been initiating important HAI research to address all 4 research domains. Basic science projects funded by NIH address the pathogenesis of deviceassociated infections and the development of strategies for preventing and/or eliminating biofilms associated with medical devices; epidemiology. Epidemiology projects funded by AHRQ and other HHS agencies include studies of the epidemiology of BSIs that occur outside of the hospital; studies to establish preventability of Clostridium difficile www.lww-medicalcare.com |

S35

Medical Care

Kahn et al


TABLE 1. Action Plan Knowledge Development Goals, 2009 and 2012 Action Plan Year 2009

2012

Knowledge Development Goals Conduct research projects to address specific knowledge gaps in basic science, epidemiology, and practices to identify gaps in the existing knowledge base of current infection control practices in hospitals. Conduct research projects to enhance implementation and impact of existing, evidence-based infection control practices. Develop a coordinated research agenda to strengthen the science for infection control and prevention in hospitals using established criteria for setting research priorities. Increase knowledge and awareness of key prevention practices to reduce healthcare–associated infections among providers, consumers, media, and general public. Perform research projects to address specific knowledge gaps including basic science, epidemiology, and prevention practices. Perform research projects to enhance implementation and evaluate the impact of existing, evidence-based infection control practices. Increase understanding of the basic science underlying HAIs and their associated pathogens. Strengthen and broaden research focused on the epidemiology of HAIs. Identify gaps in the existing epidemiologic knowledge base and develop corresponding research projects to fill those gaps. Develop, refine, and evaluate infection control interventions for the basic science and epidemiology of HAIs, while building upon the expanded understanding of the basic science and epidemiology of HAIs. Conduct implementation research of practices for which the scientific evidence provides strong support to accelerate adoption of these evidence-based practices. Expand goals for research beyond hospital settings to ambulatory and long-term care settings. Conduct research related to ASCs including: Identify needs and opportunities for HAI reduction through improvements in the process of care within ASCs. Expand current knowledge of surveillance through research to include ASC-specific measures and associated strategies for outcome measurement. Specificy a set of ASC procedures for which SSI definitions and methods should be developed. Develop, synthesize, and/or enhance evidence and tools for improving influenza vaccination of healthcare personnel, including development of the Influenza Vaccination of Healthcare Personnel as a new module in the 2012 Action Plan.

ASC indicates ambulatory surgical centers; HAI, healthcare–associated infection. Adapted from the US Department of Health and Human Services.10,11 Adaptations are themselves works protected by copyright. So in orbleder to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.

infection through a regional hospital collaborative intervention to reduce endemic rates through employment of tiered evidence-based recommendations50; studies to establish preventability of unnecessary antimicrobial use through multicenter collaborative interventions; and studies to establish the preventability of surgical site infections (SSIs) through a multicenter collaborative intervention to reduce rates. Intervention studies funded by AHRQ and HHS include a large, clusterrandomized study to assess whether ICU-wide application of a methicillin-resistant Staphyloccus aureus (MRSA) decolonization strategy was effective in reducing the transmission of HAIs and mortality compared with targeted decolonization strategy guided by active surveillance for MRSA colonization. Implementation studies include the support of (1) multidisciplinary investigation of the human cultural and organizational barriers at the unit and institutional levels that inhibit the successful implementation of prevention measures (AHRQ); (2) studies to develop and evaluate novel and potentially automatable strategies for measuring HAI transmission of epidemiologically important pathogens and related processes of care using electronic data sources routinely captured during the course of patient care (CMS); (3) studies to evaluate and validate standardized postdischarge surveillance methodology that can be used in both inpatient and ambulatory care settings using Healthcare Cost and Utilization Project (AHRQ); studies to identify and evaluate proxy measures for ventilator-associated pneumonia (VAP) (ie, acute lung injury) for interfacility comparisons that do not require stringent diagnostic approaches; and methodological studies to develop standardized methods (ie, performance methods) that are feasible, valid, and reliable for


measuring and reporting compliance with broad-based HAI prevention practices that need to be practiced consistently by a large number of healthcare personnel (eg, hand hygiene, isolation precautions, environmental cleaning practices) (HHS). The Research Working Group recognized the potential for synergies across these agencies to provide a comprehensive research agenda to prioritize, coordinate, and evaluate research efforts. For example, the Action Plan presented the example that if CDC finds a potential population with a risk factor or identifies a risk factor for an HAI, this information could help establish potential priorities for AHRQfunded research on prevention or implementation of evidence-based practices.11 NIH could focus on basic science discoveries, and CMS could test how payment policies impact utilization of evidence-based practices. Research synergies emerging across agencies within and external to HHS would support coordination and alignment and stakeholder engagement, and reduce potential duplication and enhance the impact of each agency’s work.

Establishing and Implementing Criteria for Research Priorities Another important input to the Action Plan was a set of criteria for prioritizing and funding research. The Research Working Group emphasized the importance of coordinating and prioritizing research efforts to reduce HAIs through the establishment of priorities for funding, the development of metrics for tracking research progress using these priorities, and the transparent communication of a coordinated HHS approach to research to the broader set of HAI stakeholders. r


Medical Care



TABLE 2. Four Core Research Domains and Gaps Identified in Healthcare–associated Infection Knowledge Base Identified by the Action Plan’s Research Working Group Research Domain and Mechanisms by Which Research is Expected to be Effective

Gap in HAI Knowledge Base

Basic science Basic research enhances understanding of key healthcare-associated pathogens, potentially leading to better means of diagnosis, prevention, and treatment Translation from basic to epidemiological, to implementation research can generate biologically plausible preventive measures Understanding biofilms in indwelling medical devices could significantly lower HAI incidence Epidemiology Research could enhance strategies for surveillance to Be less labor intensive Have better case-finding interrater reliability strategies Include more infections with onset in community settings even when related to in hospital activities Research directed at electronic data capture of standard processes and outcomes could decrease data collection burden and errors, and facilitate longitudinal HAI tracking across venues Research assessing how infection control interventions (eg, prophylaxis, isolation, and screening strategies) can effectively adapt to respond to the epidemiology of emergent MDR organisms The appropriate use of vaccines targeting pathogens that can be acquired in healthcare settings Infection control and prevention interventions These trials are needed to establish the efficacy of new and existing preventive interventions Collaboration across large numbers of healthcare facilities using standardized data collection to assess the impact of multifaceted prevention programs provides the opportunity to address effectiveness studies while engaging stakeholders across the nation, thus building a constituency for implementing the research findings Implementation science Implementation science research is needed to understand how Human and organizational factors that serve as barriers to implementation Technology can improve adherence Feasible, reliable, and valid standardized prevention measures can be practiced consistently across venues Research addressing which components of evidence-based bundles are effective, especially in varying contexts is necessary for mitigating HAIs and avoiding unintended adverse consequences

Understanding key pathogens Scientific basis for pathogenesis, transmission and colonization of pathogens Role of microbial biofilms in device-associated infections Current surveillance strategies need improvements

Electronic data for measuring processes and outcomes Multidrug antimicrobial resistance (MDR) Vaccines for HAIs Multicenter collaborative trials Multicenter demonstration projects

Suboptimal adherence to prevention recommendations

The interaction of the varied recommended prevention strategies is poorly understood

These gaps were identified after consideration by the Action Plan’s Research Working Group of projects and questions that could bring priority criteria into focus: (1) contribution to understanding (eg, will the project fill a knowledge gap?); (2) feasibility (eg, are human, technologic, technical, and fiscal resources available to perform the project?); (3) cost (eg, are the costs of the project justifiable for the potential health impact?; (4) impact on public health (eg, are the project results easily understood and of value to policymakers?). HAIs indicates healthcare–associated infections. Adapted from the US Department of Health and Human Services.11 Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.

Research was prioritized according to the proposed topic’s contribution to addressing research gaps, project feasibility and cost, and the anticipated impact on public health. The Research Working Group applied these criteria to research funded by the Interagency Research Working Group and identified, for each of the 4 core research domains, clinical and methodological gaps in knowledge and practice; some gaps were applicable across multiple HAIs, and some applicable only to specific HAIs, as shown in Table 2. To evaluate progress made in the Action Plan’s research domain, the Research Working Group committed to conducting periodic assessments of the research programs and the projects it has specifically supported using a priori criteria for the evaluation with a plan for iterative evaluations. The Research Working Group recommended outcomes research metrics, including documented improvements in care, published articles, dissemination of findings through conferences or other means, or other research products. Importantly, the Research Working Group also committed in applying the results of these assessments to future prioritization efforts so that the Working r


Group’s ongoing program evaluation efforts would lead to adjustments to subsequent program iterations, an approach recommended by the evaluation team.12 The development of prioritization criteria is directly responsive to Government Accounting Office and Congressional concerns about the existence of too many “high-priority” prevention practices. As described in the 2012 Action Plan, the Research Working Group’s plans to iteratively involve representatives of the 4 lead HAI funding agencies in the application and evaluation of these criteria has potential to enhance the effectiveness of funded research as time passes and as the larger HAI research community becomes aware of these criteria.

Stakeholder Engagement With Knowledge Development The collaborative style of Action Plan leadership supported engagement of key HHS agencies as well as of organizations and stakeholders external to the federal family. Our evaluation of the implementation processes used in the www.lww-medicalcare.com |

S37

Kahn et al

Action Plan’s knowledge development efforts considered the perspectives of stakeholders internal and external to HHS, including policymakers, providers, payers, state and local health departments, and patient representatives. Stakeholders interviewed by the evaluation team emphasized progress in HAI research across multiple areas and venues. They highlighted the importance of increased collaboration between NIH and other HHS agencies in efforts to increase the translation of research from basic research discovery to the development and dissemination of evidence-based prevention practices. They also emphasized progress in implementation-oriented research, highlighting the development and testing of HAI interventions for central line–associated bloodstream infections (CLABSI), catheterassociated urinary tract infections (CAUTI), and MRSA and research on safety culture and organization change strategies for HAI improvement. Some stressed the importance of building the evidence base for changing practice behavior, by utilizing precise specification of terms relevant to physicians and other healthcare professionals. For example, a member of a professional group stated, “The fact that there are clear definitions, allows you to know what people are talking about; and there’s evidence. For physicians, evidence is key.” Both internal and external stakeholders also emphasized the importance of all 4 research domains that the Action Plan emphasized (Table 2), noting some challenges coordinating federal research priorities across agencies. Interviewed stakeholders also highlighted the need for additional research to support the prioritization criteria for HAI prevention, for the specification of interventions to be adopted particularly in different contextual circumstances, and for specifying implementation details in driving practice change behavior. Interviews revealed interest in more research into the integration of new clinical microbiological molecular testing methods for HAI identification and validation; the impact of value-based purchasing on clinicians and staff who work with HAIs as well as on HAI rates, and the effectiveness of deploying antimicrobial stewardship strategies. Interview informants underscored the value of both quantitative and qualitative research.

HAI Research and Implementation Programs and Projects The AHRQ, CDC, CMS, NIH, and OASH federal agencies account for the majority of federal research dollars expended to prevent HAIs. Our evaluation compiled a Program and Project Inventory (PAPI) to document the HAI prevention activities of these 5 agencies for fiscal year 2010 (the only year for which data were available for all participating agencies) in terms of system function addressed, HAI addressed, healthcare and hospital setting, and type of collaboration. The PAPI was important for understanding the extent to which research and prevention activities address key issues and for identifying gaps. Table 3 shows that 70% of 103 documented programs and projects included a focus on knowledge development, whereas 64% addressed adoption of prevention practices with some variability by agency. Although NIH research is


Medical Care


foundational for much HAI research and informs much HAI prevention research conducted by other agencies, NIH research could not be included in this table because NIH uses a different system for categorizing research than the other agencies. Table 3 shows that compared with other agencies, CMS was more likely in 2010 to be involved in prevention practice adoption programs and projects than in research. The PAPI showed that all 6 HAIs identified as high priority by the Action Plan were addressed by the agencies collectively and individually. Seventy-four percent (N = 76) of programs or projects were described by agencies as addressing at least one of the 6 Action Plan HAIs; 39% addressed one of the target HAIs, 16% addressed 2, and 32% addressed all 6. AHRQ and OASH programs and projects were much more likely to address only 1 HAI, whereas CDC’s were more likely to address all 6 target HAIs. PAPI found that multiple efforts addressed hand hygiene and healthcare worker vaccinations. The inventory also showed that programs and projects span federal, regional, and state levels, and are distributed across a variety of inpatient and ambulatory settings. Overall, just under one third of programs or projects with available data were conducted with funds from their own funding agency, whereas more than one fourth involved collaboration with other HHS agencies; more than one third involved collaboration with other nonHHS agencies; and 7% involved both HHS and non-HHS collaborators. Given that each agency has its own mission, this distribution seems reasonable, allowing the uniqueness of each agency to be preserved while also illustrating substantial efforts across agencies to collaborate.

Prevention Practice Adoption Goals Action Plan working groups collaborated to draw from the HAI evidence base derived from knowledge development and research to build support for the adoption of HAI prevention practices. Within the Action Plan working group structure, the Prevention and Implementation Working Group was tasked with prioritizing existing recommended clinical practices to facilitate implementation in healthcare organizations, the Incentives and Oversight Working Group explored opportunities for evaluating compliance with infection control practices in hospitals, and the Outreach and Messaging Working Group developed a coordinated plan for national messaging for HAI prevention.10,11 The overarching HAI Prevention Practice Adoption goal from the 2009 Action Plan was the identification of key HAI prevention strategies across healthcare settings where these strategies are needed and could be applied.10 Action Plan leaders recognized the importance of developing and testing interventions supported by research to increase adherence to recommended HAI practices. The Action Plan recommended applying implementation research to the subset of prevention practices supported by strong scientific evidence in an effort to accelerate adoption. The 2012 Action Plan11 added new prevention practice adoption goals applicable to information system and technology and new venues, including ASCs and end-stage renal disease (ESRD) facilities,51–53 as well as to healthcare personnel.54 r


Medical Care



TABLE 3. Four Agency Program and Project Inventory (PAPI) for Healthcare–associated Infections (%) Four Agencies (%) N = 103 Type of system function pursued with HHS Action Plan activities Infrastructure development 57 Data and monitoring 51 Knowledge development 70 Adoption of prevention practice 64 Type of healthcare setting Hospital—any 75 ASC 42 ESRD center 48 Long term care center 44 Type of hospital setting Intensive care center 45 Operating room 26 Medical/surgical center 41 Emergency department 41 Outpatient 33 Pharmacy 31 Other 22 Not specified 57 Type of interagency collaboration* None 30 Only with other HHS agencies 27 Other with non-HHS organizations 35 Both with other HHS and with non-HHS agencies 7

AHRQ (%) N = 32

CDC (%) N = 32

CMS (%) N = 15

OASH (%) N = 24

25 25 75 22

56 84 78 75

53 47 20 87

71 63 75 83

53 3 0 33

100 94 100 94

73 0 27 0

71 50 54 42

6 0 6 3 3 0 6 31

100 100 94 100 97 53 6 100

13 13 7 0 0 0 27 40

42 38 38 38 38 38 4 62

44 9 34 13

22 28 47 3

9 27 64 0

33 58 8 0

Within sections of the table (noted with bolded text), column percentages may sum to >100% because agencies could indicate >1 categorical response per program or project. *Four CMS PsPs are omitted from this analysis of collaboration because of missing data for collaboration. AHRQ indicates Agency for Healthcare Research and Quality; ASC, ambulatory surgical center; CDC, Center for Disease Control; ESRD, end-stage renal disease.

Prevention Practice Adoption Inputs and Implementation Processes The key prevention practice input was the development of priority prevention recommendations and guidelines. Prioritization was supported by the development of a standardized approach for developing quality measures and a formal mechanism for assessing the quality of evidence and strength of recommendations. Important implementation processes included use of multiple strategies and toolkits to provide education and dissemination, support measurement, and provide incentives to stimulate adherence to prevention practices.

Development of Priority Recommendations Action Plan leaders drew upon existing and emerging research to prioritize recommendations for CAUTI, SSI, CLABSI, and VAP prevention, using the multistep process presented in Table 4. CDC updated its process for identifying implementation priorities based upon supporting scientific evidence that a practice is effective/beneficial, associated with recognized gaps in current implementation, synergistic with other related practices, and has potential impact for achieving desired outcomes.10 A concise set of HAI-related guidelines emerged from these updates, including evidence tables with sections on implementation, auditing and prioritization, and with plans for regular guideline updates and the establishment of new strategies to address prevention gaps.56,57 CDC has also developed recommendations for infection prevention in ambulatory settings.58 r


Over time, CMS standardized its approach for developing quality measures and prioritized those measures with goals and objectives set forth by the Action Plan and the National Quality Strategy.59

Research to Define Effective Interventions A strength of the Action Plan’s progress is that multiple Action Plan agencies have prioritized recommendations using rigorous systems, such as the tool for grading the quality of evidence and strength of recommendation developed by the international Grading of Recommendations Assessment, Development and Evaluation Working Group.60–62 In 2012, a follow-up AHRQ Evidence-based Practice Report presented new evidence regarding the effectiveness of interventions to increase adherence to prevention practices and/or to reduce HAIs.63 They reported moderate strength of evidence for adherence to evidence processes and infection rates for CLABSI, VAP, SSI, and CAUTI following exposure to combinations of interventions, including either audit and feedback plus provider reminder systems, or audit and feedback plus organizational change and provider education base strategies. However, when provider reminder systems were introduced alone, studies reported low strength of evidence for improved adherence to prevention methods and for reducing infection rates. They noted insufficient evidence for HAI reduction following interventions in out-of-hospital settings, for cost savings from quality-improvement strategies, and for including clinical contextual factors in specification of effective interventions. www.lww-medicalcare.com |

S39

Kahn et al

Medical Care


TABLE 4. Five-Step Process Used by CDC for Selecting High-Priority Recommendations from the Guidelines for the Prevention of CAUTI, BSI, VAP, and SSI (HHS, 2009) (1) Category 1A and 1B recommendations were included in the pool of recommendations considered for prioritization. In addition, category 1C recommendations, which included state and federal regulations regardless of evidentiary support, also were considered.*w (2) CDC subject-matter experts in infectious diseases, infection control, and healthcare epidemiology assessed each recommendation for urgency, relative importance for HAI prevention, the degree to which it is currently implemented by all healthcare facilities (ie, whether there is a gap in current implementation), and how the recommendation relates to other healthcare delivery recommendations. (3) Recommendations were grouped based on interdependence in implementation. These groupings are referred to as “priority modules.” (4) Priority modules, each of which contains interdependent and thematically related recommendations for clinical practice, were mapped to relevant recommendations for implementation and auditing. (5) Priority modules were reviewed and refined by an expanded CDC group and by HICPAC. *Category 2 recommendations, without strong evidence to support their efficacy, were not included. The prioritization for VAP prevention included recently compiled recommendations from the SHEA)/IDSA Compendium of Strategies to Prevent Healthcare–associated Infections in Acute Care Hospitals to capture practices not included in the 2003 CDC guideline. wStrength of recommendation and quality of evidence were adapted from the Canadian Task Force.55 BSI indicates bloodstream infection; CAUTI, catheter-associated urinary tract infection; CDC, Center for Disease Control; HAI, healthcare–associated infection; HHS, Health and Human Services; HICPAC, Healthcare Infection Control Practices Advisory Committee; SSI, surgical site infection; VAP, ventilator-associated pneumonia. Adapted from the US Department of Health and Human Services.10 Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.

For the first time, a study addressing prevention of ambulatory HAIs was included, although only one. In 2013, an additional critical analysis of evidence for patient safety practices was reported, this time incorporating data and analyses about context, implementation, and unintended harms from patient safety effectiveness literature and from implementation studies.64 Six of the 10 patient safety strategies that were identified as having strength and quality of evidence for effectiveness and implementation (so that they were ready to be encouraged for adoption by healthcare providers) specifically related to HAI prevention. In response to the recognition of challenges associated with implementing VAP metrics31 both the Research and Prevention Working Groups, and the Implementation Action Plan Working Groups aligned with CDC to identify the problems and plan a new and feasible alignment between research and the development of prevention practices.65 Multidisciplinary collaborative inputs from these experts were finally able to break the impasse in measuring HAI outcomes among users of mechanical ventilators by constructing a new ventilatory-associated events paradigm reflecting research advances in both clinical and implementation science.

Implementation of HAI Prevention Practices Action Plan activities to enhance prioritization of prevention practices also addressed implementation and adoption. The Influenza Vaccination Working Group adopted practices recommended by the Advisory Committee on Immunization Practices to encourage influenza vaccination among healthcare personnel.66 These practices were complemented by toolkits and other strategies providing education, role modeling, improved access to vaccines, measurement and feedback of immunization rates, and by legislation and regulation endorsed by CDC, HICPAC, and AHRQ.66–68 The Action Plan also spurred progress in the dissemination of prevention practices through specific major initiatives, including AHRQ’s expansion of the Comprehensive Unit-based Safety Program (CUSP) system for reporting and


reducing CLABSIs. Although CUSP began by aiming to increase the number of participating ICU in hospitals in 10 states to implement CUSP for CLABSI, it then expanded with open participation to all 50 states, Puerto Rico, and the District of Columbia, expanded CUSP into non-ICU hospital settings and to additional conditions, such as CAUTI.69,70 The Surgical Unit Safety Program is a patient safety program initiated in 2011 that also built on the success of CUSP for CLABSI. CDC, with American Reinvestment and Recovery funding, has supported state health departments in convening stakeholders to focus on HAI prevention, established prioritized state-specific HAI prevention plans, and incorporated public health roles into existing and new HAI prevention work with local hospitals and developed collaborative networks to stimulate adherence to evidence-based prevention measures.71 CMS introduced value-based purchasing to stimulate adherence to prevention practices in hospital, ambulatory surgical, and ESRD settings through the development and tracking of prevention metrics and targets named in the HHS Action Plan.72,73 Furthermore, HHS federal agencies are increasingly collaborating in developing multifaceted programs to stimulate adoption of prevention practices. Valuebased purchasing is applied nationally by CMS using hospital71,72 and dialysis center data74 collected and monitored using data sources specified by the Action Plan, at the state level as state laws have increasingly mandated public reporting of HAI rates,75 and as health plans have encouraged participation in statewide HAI collaboratives and research projects.76 Quality Improvement Organizations, in their ninth and 10th Scopes of Work have been required to form partnerships with national, state, and local stakeholders to broaden the impact of HAI reduction strategies generally, and to reduce CLABSI in particular.77 A field example shows CMS partnering with AHRQ and CDC to facilitate Quality Improvement Organization access to CUSP training sessions. This improved training for healthcare personnel played an active role in facilities’ enrollment and reporting in the National Healthcare Safety Network, thus aligning their r


Medical Care


resources with those channeled to states for HAI capacity improvement. In the ambulatory setting, progress has been made through CDC and CMS developing survey tools and training materials in ASCs to support implementation of recommended ambulatory guidelines.78 CMS is continuing to build its quality measurement and public reporting to include measurement in nursing homes, home health agencies, and physician offices as a supplement to hospitals and dialysis facilities.

Challenges to Adoption of Prevention Practices Implementation burden and “campaign fatigue:” Although the Action Plan took steps to prioritize recommendations for HAI prevention practices, the implementation burden on healthcare providers and organizations was reported to have grown due to the proliferation of HAI prevention practices, policies, programs, and initiatives. This problem, referred to by 1 interview respondent as “campaign fatigue,” became especially notable as CMS introduced the Partnership for Patients’ initiative to accelerate improvements in quality, safety, and affordable healthcare for all Americans. Although leaders of the Partnership for Patients and the Action Plan took most of a year to intensively coordinate their approaches to HAI prevention, stakeholder interview respondents emphasized the need for greater integration and consolidation of core prevention strategies and functions across HAIs and other safety areas to make the work of healthcare organizations and providers more manageable. As one respondent commented: “There’s 5 or 10 different programs being rolled out without anybody overseeing how they work together. Partnership for Patients, for wound care, acronyms flying all over the place, I don’t quite see how it’s being pulled together. There’s no one line where it’s all going.” Difficulty in implementing some practices: Stakeholders also noted several challenging areas for adoption of prevention practices. These include practices for addressing C. difficile and MRSA given the community transmission component of these HAIs, CLABSI outside ICU due to differences between ICU and other inpatient settings, and complexities associated with ensuring consistent hand washing adherence across venues and individuals. Stakeholders also emphasized the need for greater emphasis on development and dissemination of prevention strategies in ASCs and ESRD centers. An additional concern has been the extensive resources required by sites and states to staff and coordinate these multiple efforts. Concordance between areas needing further emphasis according to stakeholders internal and external to HHS and priority topics identified by the Research Working Group is notable.

DISCUSSION Since the introduction of the Action Plan, HHS has made substantial progress in prioritizing research projects, translating findings from those projects into practice, and designing and implementing research projects in multisite practice settings. In both the areas of knowledge development and prevention practice adoption, the responsible Working Groups of the Action Plan (eg, Research, Prer



vention, and Implementation) sought not only to guide key funding efforts, but also to develop a prioritized approach with criteria that could be used to guide future decisions. Leading up to the release of the Action Plan and since that time, important activities by multiple federal and state agencies, as well as by researchers and practitioners, have built a growing awareness of the importance of HAIs as a major national epidemic, and of the need for a systematic and coordinated approach to stem the tide of the epidemic.79 Concomitantly, the methods, challenges, and opportunities associated with advancing the science of patient safety, and the application of safety principles to the goals of the Action Plan, continue to move forward.36,64,65,80,81

Engaging a Broad Coalition of Stakeholders The most important role for HHS in research and prevention practice adoption lies its focused approach that engages a broad coalition of stakeholders. This approach can involve scientists across the 4 core research domains, building coordination and alignment across funding agencies and research teams, and thus identifying opportunities for accountability, incentives, and resource opportunities to efficiently respond to research gaps. Focusing on a broad coalition of stakeholders also facilitates the complex task of translating research findings into practice by establishing criteria for effective interventions that consider all 4 research domains and the linkages between them, applying criteria to available intervention options, and providing opportunities for endorsement by diverse key stakeholders, including those who implement the prevention practices and payers who can incentivize use of the interventions. Continuing to engage a broad range of stakeholders moving forward will be especially important, given the context of emerging research methods, new organizational structures and fiscal policies for supporting clinical and policy advances, changing specifications for valid processes and outcomes, updated guidelines, and a growing role for technology with HAI data and monitoring.

Emphasizing the Relationship Between Research and Prevention Practice Adoption The broad translational view of research taken by the Action Plan which spans from bench to hospital to community ambulatory and long-term-care settings supports efficiencies by aligning research and prevention practice methods. Research and practice adoption relate to each other, with both depending upon the identification of key questions or challenges that can be informed through thoughtful analysis of quantitative and/or qualitative data. A better research evidence base is believed to lead to more effective practice adoption.48,82

Supporting Infrastructure and Accountability In responding to the HAI epidemic, the Action Plan smartly recognized that federal efforts to support research and practice adoption down to the point of care would be most effective when supported by other system functions, including infrastructure development and data and monitoring. By involving key HHS agencies and a Steering www.lww-medicalcare.com |

S41

Kahn et al

Committee that includes a diverse set of organizations and stakeholders, and creating a process to link federal, regional, state, and local HAI prevention efforts, the Action Plan developed an infrastructure to support the research agenda and strategies for prioritizing prevention practices. Some major successes came with accountability measures that provided incentives to encourage more healthcare facilities to employ specific prevention practices; others came with the development of survey tools and training materials, and with the use of improved data and monitoring systems. Such efforts have likely contributed to stakeholders’ reported perceptions of greater momentum in HAI activities in federal, state, and private sectors as well as increased experience with implementation and adherence to HAI prevention practices, even if change in practice from these efforts is not yet clear.83 By identifying data and monitoring systems to support HAI-related metrics and targets, the Action Plan developed systems to support multisite research projects that can address external validity and reliability, thus providing important contextual inputs relevant for adoption of practices. Infrastructure and data and monitoring advances are likely to help build the research base, and in turn, to support evidence-based prevention practices. Benefits are likely to be gained from infrastructure, and from data and monitoring support for research and adoption strategies. Research and prevention practices are also likely to benefit from the basic, epidemiological, and implementation science communities having joined forces to better define mechanisms and responsibilities for translating HAI research into practice.

Medical Care

Furthermore, the Action Plan’s approach to knowledge development decisions and implementation strategies is supported by 5 system properties, which aim to support large-scale system change through prioritization, coordination and alignment, accountability and incentives, stakeholder engagement, and resources, as illustrated in Table 5. For example, the Action Plan’s introduction of an interagency Research Work Group placed a renewed focus on coordinating federal efforts, including those of NIH and other HHS agencies. Interviews have acknowledged this progress and coordination across agencies. If the translation of NIH basic science to bedside and community-wide implementation research and ultimately to evidence-based prevention practice adoption is to become a reality, these ongoing interagency collaborations must remain a priority.

Sustaining Progress Key to sustaining system capacity for research and practice adoption is to embed the identification and pursuit of research questions and prevention practices into routine work, systems, and culture, and to identify and develop core prevention practices that are common and easily learned across settings and HAI conditions.



TABLE 5. Links Between System Properties and Advances in the Knowledge Development and Prevention Practice Adoption System Functions System Properties Prioritization Coordination and alignment Accountability and incentives

Stakeholder engagement

Resources

Improving Coordination, Prioritization, and Accountability

Knowledge Development Decisions and Implementation Strategies Agency focus on specific HAIs is associated with funding opportunities, training programs, and national and regional meetings HHS agencies have been participating with each other and with agencies and stakeholders external to HHS to leverage expertise in science, technology, implementation, and resources to address HAIs Substantial policy advances related to accountability and incentives to tracking and reducing HAIs drive the need for new conceptual models for and empirical research related to implementation science in general, and accountability and incentives in particular The broad set of knowledge development topics addressed by the Action Plan call for multidisciplinary inputs that support engagement of a broad set of stakeholders spanning basic and/or laboratory scientists; epidemiologists; infection control interventionists; and implementation scientists These experts are joined by consumer advocates, hospital administrators, and other external stakeholders who increasingly share interests in the methods used for enhancing the elimination of HAIs Involving stakeholders in research increases the likelihood that they will believe the validity of the findings and be able to identify the subset of interventions most applicable to their setting Research documenting the scope of HAIs within and across venues highlights the multiple challenges and opportunities associated with HAI elimination Substantial resources are required to support research targeting basic science, epidemiology, infection control, and implementation science The Action Plan has leveraged existing science, technologies, and organizational structures to serve as resources to support HAI knowledge development Efforts aimed at prioritization, coordination, and alignment, implementation of policies to support accountability and incentives to reduce HAIs, and stakeholder engagement, paired with coordinated messaging strategies, have effectively garnered existing and new resources to support HAIs

HAI indicates healthcare–associated infection.

Characterizing Goals, Strategies, and Outcomes of HAI Programs and Projects Results of the PAPI of agency-sponsored projects demonstrate substantial coordination across federal and local initiatives for involving sites in research and adoption of prevention practices. However, although progress has been made, 1 strategy that could further support the coordination and integration of research and adoption efforts would be the development of a prospective PAPI to characterize the goals, strategies, and outcomes of federal, regional, and state HAI programs and projects. This was recommended by the Research Working Group. Although the PAPI developed by the r


Medical Care


evaluation team showed evidence of coordination and integration, its ability to identify opportunities for synergy and areas of redundancy and gaps was somewhat limited because each agency has its own system of tracking programs and projects. If HHS finds a systematic inventory of HAI programs and projects useful, efforts should be made so that agencies can agree in advance about terms that could generate a PAPI that is even more responsive to agency data structures and needs. A more centralized approach to tracking research and implementation of programs and projects could lead to a more centralized approach to resource allocation. It is difficult to know at this time whether a more centralized approach would be preferable to the current program that aims to, and increasingly is successful at, aligning the efforts of distinct agencies. Since the Action Plan has been introduced, these agencies have been collaborating in ways never before realized. This has been a learning process for interagency collaboration as each agency has been able to refine its own contributions, identify opportunities for new collaborations, avoid unnecessary redundancies, and identify areas for potential synergies.

Potential for Long-term Impact Translation from basic science to dissemination of evidence prevention practice strategies is a complex activity, and history has shown the importance of time in allowing paradigm shifts in healthcare delivery to mature and disseminate.84,85 Efforts are being made to address ongoing challenges in applying findings from the evidence base to state and regional quality-improvement efforts. Although we wait for time to reveal the effectiveness of the Action Plan’s longer-term impacts, it is fair to say now that we see evidence that research goals established by the Action Plan having been incorporated into resource and prioritization decisions. In parallel, we have seen an unprecedented flow of inputs and implementation strategies consistent with Action Plan goals that have resulted in the development of new prevention practice evidence,6 and a big push toward implementation spanning federal, regional, state, and local programs. It is important now to allow the current structure for research and prevention practices to mature by sustaining the coordinated approach to HAI prevention that the Action Plan has motivated. REFERENCES 1. Leape LL, Berwick DM, Bates DW. What practices will most improve safety? JAMA. 2002;288:501–507. 2. Shojania KG, Duncan BW, McDonald KM, et al. Safe but sound: patient safety meets evidence-based medicine. JAMA. 2002;288:508–513. 3. Forster AJ, Shojania KG, Van Walraven C. Improving patient safety: moving beyond the “hype” of medical errors. CMAJ. 2005;173: 893–894. 4. Auerbach AD, Landefeld CS, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357:608–613. 5. Lenfant C. Clinical research to clinical practice—lost in translation? N Engl J Med. 2003;349:868–874. 6. Zerhouni EA. Translational and clinical science—time for a new vision. N Engl J Med. 2005;353:1621–1623. 7. Gelijns AC, Gabriel SE. Looking beyond translation—integrating clinical research with medical practice. N Engl J Med. 2012;366: 1659–1661. r



8. The Leapfrog Group. Early identification and prevention of hospitalacquired infections: evidenced based approach for improving management of HAIs. Available at: http://www.leapfroggroup.org/media/file/ leapfrogwebinarOct12FINAL.pdf. Accessed May 1, 2013. 9. Institute for Healthcare Improvement. Protecting 5 million lives from harm. Available at: http://www.ihi.org/IHI/Programs/Campaign/Campaign.htm? TabId = 2#PreventSurgicalSiteInfection. Accessed July 25, 2007. 10. US Department of Health and Human Services. Action Plan to Prevent Healthcare-Associated Infections. Washington, DC. 2009. Available at: http://www.hhs.gov/ash/initiatives/hai/actionplan/hhs_hai_action_plan_ final_06222009.pdf. Accessed April 1, 2013. 11. US Department of Health and Human Services. National Action Plan to prevent healthcare-associated infections: roadmap to elimination. 2012. Available at: http://www.hhs.gov/ash/initiatives/hai/framework.html. Accessed April 1, 2013. 12. Kahn KL, Mendel P, Weinberg DA, et al. Approach for conducting the longitudinal program evaluation of the US Department of Health and Human Services National Action Plan to prevent healthcare-associated infections: roadmap to elimination. Med Care. 2014;52(2 suppl 1): S9–S16. 13. Mendel P, Weissbein D, Weinberg DA, et al. Longitudinal Program Evaluation of the HHS Action Plan to Prevent Healthcare-associated Infections: Year 1 Report. Santa Monica: RAND; 2011. 14. Mendel P, Siegel S, Leuschner KJ, et al. The national response for preventing healthcare-associated infections: infrastructure development. Med Care. 2014;52(2 suppl 1):S17–S24. 15. Kahn KL, Mendel P, Leuschner KJ, et al. The national response for preventing healthcare-associated infections: data and monitoring. Med Care. 2014;52(2 suppl 1):S25–S32. 16. Stufflebeam D. The CIPP model for evaluation. In: Stufflebeam DL, Madaus GF, Kellaghan T, eds. Evaluation Models: Viewpoints on Educational and Human Services Evaluation. Boston: Kluwer Academic Publishers; 2000:279–317. 17. Joint Commission on Accreditation of Hospitals. Accreditation Manual for Hospitals. Chicago: Joint Commission on Accreditation of Hospitals; 1976. 18. Scheckler WE. Hospital epidemiology is the paradigm for patient safety. Infect Control Hosp Epidemiol. 2002;23:47–51. 19. Garner JS, Jarvis WR, Emori TG, et al. CDC definitions for nosocomial infections, 1968. Am J Infect Control. 1988;16:128–140. 20. Emori TG, Culver DH, Horan TC, et al. National nosocomial infections surveillance system (NNIS): description of surveillance methodology. Am J Infect Control. 1991;19:19–35. 21. National Nosocomial Infections Surveillance System. Nosocomial infection rates for interhospital comparison limitations and possible solutions. Infect Control Hosp Epidemiol. 1991;12:609–612. 22. Centers for Disease Control and Prevention. Monitoring Hospitalacquired Infections to Promote Patient Safety. Atlanta, GA: MMWR; 2000:149–153. 1990-1999. 23. Scheckler WE, Brimhall D, Buck AS, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: a consensus panel report. Infect Control Hosp Epidemiol. 1998;19:114–124. Am J Infect Control. 1998;26: 47–60. 24. Friedman C, Barnette M, Buck AS, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings: a consensus panel report. Infect Control Hosp Epidemiol. 1999;20:695–705. 25. Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:250–278. 26. Siegel JD, Rhinehart E, Jackson M, et al. Management of multidrugresistant organisms in healthcare settings, 2006. 2013. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/ar/MDROGuideline2006.pdf. Accessed July 30, 2008. 27. Mermel LA, Farr BM, Sherertz RJ, et al. Guidelines for the management of intravascular catheter-related infections. Clin Infect Dis. 2001;32: 1249–1272. 28. O’Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Infect Control Hosp Epidemiol. 2002;23:759–769.

www.lww-medicalcare.com |

S43

Kahn et al

29. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2003;51(RR-16):1–45. quiz CE41-CE44. 30. Centers for Disease Control and Prevention. Guidelines for preventing healthcare-associated pneumonia, 2003 recommendations of CDC and the healthcare infection control practices advisory committee. MMWR. 2004;53(No. RR-3):1–36. 31. Muto CA, Jernigan JA, Ostrowsky BE, et al. SHEA guidelines for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus. Infect Control Hosp Epidemiol. 2003;24:362–386. 32. Wong ES, Hooton T. Guideline for prevention of catheter-associated urinary tract infections. Available at: http://www.cdc.gov/ncidod/dhqp/ gl_catheter_assoc.html. Accessed July 25, 2007. 33. Klompas M. Does this patient have ventilator-associated pneumonia? JAMA. 2007;297:1583–1593. 34. Yokoe DS, Mermel LA, Anderson DJ, et al. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S12–S21. 35. Glasziou P, Ogrinc G, Goodman S. Can evidence-based medicine and clinical quality improvement learn from each other? BMJ Qual Saf. 2011;20(suppl 1):113–117. 36. Rothman KJ, Greenland S. Modern Epidemiology. Philadelphia: Lippincott-Raven; 1998. Greenlander Sander AND infection trials. 37. Harris AD, Bradham DD, Baumgarten M, et al. The use and interpretation of quasi-experimental studies in infectious diseases. Clin Infect Dis. 2004;38:1586–1591. 38. Adams K, Corrigan J. Institute of Medicine Committee on Identifying Priority Areas for Quality Improvement. Priority Areas for National Action: Transforming Health Care Quality. Washington, DC: National Academics Press; 2003. 39. Consumer Reports. How we rate hospitals: answers to question about how the hospitals are related and how you should use the information. Available at: http://www.consumerreports.org/cro/2012/10/how-werate-hospitals/index.htm. Accessed March 12, 2013. 40. McKibbon L, Horan TC, Tokars JI, et al. Guidance on public reporting of healthcare-associated infections: recommendations of the healthcare infection control practices advisory committee. Infect Control Hosp Epidemiol. 2005;26:580–587. 41. AHRQ, Quality and Patient Safety. Health care-associated infections: description of AHRQ-funded projects to reduce healthcare-associated infections. 2013. Available at: http://www.ahrq.gov/professionals/qualitypatient-safety/patient-safety-resources/resources/hais.html. Accessed December 19, 2013. 42. Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion (DHQP). 2011. Available at: http://www.cdc.gov/ ncezid/dhqp/. Accessed April 3, 2013. 43. “3 Formulating New Rules to Redesign and Improve Care.” Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001. 44. Shojania KG, Duncan BW, McDonald KM, et al. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/ Technology Assessment, Number 43 (Prepared by the University of California at San Francisco-Stanford Evidence-based Practice Center Under Contract No. 290-97-0013). Rockville: Agency for Healthcare Research and Quality; 2001. 45. Ranji SR, Shetty K, Posley KA, et al. Prevention of healthcareassociated infections. In: Shojania KG, McDonald KM, Wachter RM, Owens DK, eds. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies Vol. 6. Technical Review 9 (Prepared by the Stanford University-UCSF Evidence-Based Practice Center Under Contract No. 290-02-0017). Rockville: Agency for Healthcare Research and Quality; 2007:1–67. 46. U.S. Government Accountability Office. US Government Accountability Office. Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections: GAO-08-283, March 31, 2008. Washington D.C. 20548.


Medical Care


47. The Research Committee of the Society of Healthcare Epidemiology of America. Enhancing patient safety by reducing healthcare-associated infections: the role of discovery and dissemination. Infect Control Hosp Epidemiol. 2010;31:118–123. 48. Kahn KL, Ryan G, Beckett M, et al. Bridging the gap between basic science and clinical practice: a role for community clinicians. Implement Sci. 2011;6. [Online article]. 49. Woolf SH. The meaning of translational research and why it matters. JAMA. 2008;299:211–213. 50. Siegel S, Kahn KL. Regional interventions to eliminate healthcareassociated infections. Med Care. 2014;52(2 suppl 1):S46–S53. 51. US Department of Health and Human Services. HHS Action Plan to prevent health care-associated infections: ambulatory surgical centers. 2013. Available at: http://www.hhs.gov/ash/initiatives/hai/actionplan/ hai-action-plan-asc.pdf. Accessed May 1, 2013. 52. US Department of Health and Human Services. Report to congress: Medicare ambulatory surgical center value-based purchasing implementation plan. Available at: https://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/ASCPayment/Downloads/C_ASC_RTC-2011.pdf. Accessed December 19, 2013. 53. US Department of Health and Human Services. HHS Action Plan to prevent health care-associated infections: end-stage renal disease facilities. 2013. Available at: http://www.hhs.gov/ash/ initiatives/hai/actionplan/hai-action-plan-esrd.pdf. Accessed April 25, 2013. 54. Fiore AE, Uyeki TM, Broder K, et al. Prevention and Control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. Available at: http://www.cdc.gov/mmwr/ preview/mmwrhtml/rr59e0729a1.htm. Accessed April 25, 2013. 55. Guyatt GH, Oxman AD, Schunemann HJ. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. Br Med J. 2008;336:924–926. 56. Gould GV, Umscheid CA, Agarwal RK, et al. Guideline for prevention of catheter-associated urinary tract infections. 2009. Available at: http:// www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf Accessed April 20, 2013. 57. O’Grady NP, Alexander M, Burns LA, et al. 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections. Available at: http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html. Accessed April 25, 2013. 58. Centers for Disease Control and Prevention. Guide to infection prevention for outpatient settings: minimum expectations for safe care. 2011. Available at: http://www.cdc.gov/HAI/settings/outpatient/outpatientcare-guidelines.html. Accessed April 25, 2013. 59. National Strategy for Quality Improvement in Health Care. Available at: http://www.ahrq.gov/workingforquality/. Accessed December 19, 2013. 60. Gorber SC, Singh H, Pottie K, et al. Process for guideline development by the reconstituted Canadian Task Force on Preventive Health Care. CMAJ. 2012;184:1575–1581. 61. Ahmed F, Temte JL, Campos-Outcalt D, et al. Methods for developing evidence-based recommendations by the Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention (CDC). Vaccine. 2011;29:9171–9176. 62. Owens DK, Lohr KN, Atkins D, et al. AHRQ series paper 5: grading the strength of a body of evidence when comparing medical interventionsagency for healthcare research and quality and the effective health-care program. J Clin Epidemiol. 2010;63:513–523. 63. Rothenberg BM, Marbella A, Pines E, et al. Prevention of HealthcareAssociated Infections. Closing the Quality Gap: Revisiting the State of the Science. Evidence Report/Technology Assessment No. 208. (Prepared by the Blue Cross and Blue Shield Association Technology Evaluation Center Evidence-Based Practice Center under Contract No. 290-2007-1005 8-I). Rockville, MD: Agency for Healthcare Research and Quality; 2012. Available at: http://www.effectivehealthcare.ahrq.gov/ehc/products/335/ 1334/EvidReport208Part6-HAIs_FinalReport_20121127.pdf. Accessed December 19, 2013. 64. Shekelle PG, Pronovost PJ, Wachter RM, et al. Making health care safer: a critical review of evidence supporting strategies to improve patient safety. Ann Intern Med. 2013;158(5 part 2):365–368. Available at: http:// annals.org/article.aspx?articleid = 1657884. Accessed April 1, 2013. r


Medical Care


65. National Healthcare Safety Network e-News. Ventilator-associated event (VAE) surveillance for adults special edition. Available at: http://www.cdc.gov/nhsn/PDFs/Newsletters/VAE-Newsletter-September 2012.pdf. Accessed April 15, 2013. 66. Centers for Disease Control and Prevention. Influenza vaccination of health-care personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). 2006. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5502a1.htm. Accessed March 17, 2013. 67. Centers for Disease Control and Prevention. Healthcare-associated Infections (HAIs). Available at: http://www.cdc.gov/HAI/settings/out patient/outpatient-settings.html. Accessed April 15, 2013. 68. AHRQ Health Care Innovations Exchange. Innovations and tools to improve quality and reduce disparities; policy innovation profile: health system makes annual influenza immunization a condition of ongoing employment, leading to near complete vaccination of workforce. Available at: http://www.innovations.ahrq.gov/content.aspx?id = 3694. Accessed April 25, 2013. 69. Agency for Healthcare Research and Quality. Using a Comprehensive Unit-based Safety Program (CUSP) to prevent healthcare-associated infections. 2013. Available at: http://www.ahrq.gov/professionals/qual ity-patient-safety/cusp/index.html. Accessed April 28, 2013. 70. Battles JB, Farr SL, Weinberg DA. From research to nationwide implementation: the impact of AHRQ’s HAI Prevention Program. Med Care. 2014;52(2 suppl 1):S91–S96. 71. Srinivasan A, Craig M, Cardo D. The power of policy change, federal collaboration, and state coordination in healthcare-associated infection prevention. Clin Infect Dis. 2012;55:426–431. 72. DHHS Centers for Medicare & Medicaid Services 42 CFR Parts 412, 413, 424, and 476 [CMS–1588–F] RIN 0938–AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals’ Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers; 53258 Federal Register/Vol. 77, No. 170/Friday, August 31, 2012/Rules and Regulations. Federal Register, Vol 77, Friday August 31, 2012, No. 170, Part II. Available at: http://www.gpo.gov/fdsys/pkg/ FR-2012-08-31/pdf/2012-19079.pdf. Accessed April 25, 2013. 73. 111th Congress, 2009-2010. Text as of May 18, 2009 (Reported by House Committee). American Recovery and Reinvestment Act of 2009. Pub L No. 111-115, Stat 1 2009. http://www.gpo.gov/fdsys/pkg/BILLS-

r



74.

75.

76.

77.

78.

79.

80.

81.

82. 83. 84.

85.

111hr2182rh/pdf/BILLS-111hr2182rh.pdf. Accessed December 26, 2013. NHSN and CMS End Stage Renal Dialysis Quality Incentive Program (ESRD QIP) Rule. Available at: http://www.cdc.gov/nhsn/dialysis/faq/ faq-ESRD-QIP.html. Accessed December 19, 2013. CDC. HAI Prevention Activities, Facilities in these states are required by law to report HAI data to NHSN. Available at: http://www.cdc.gov/ hai/stateplans/required-to-report-hai-NHSN.html. Accessed December 19, 2013. Centers for Disease Control and Prevention. State-based HAI Prevention, State-based HAI Prevention Success Stories from States. Available at: http://www.cdc.gov/hai/state-based/success_stories.html. Accessed December 19, 2013. Centers for Medicare and Medicaid Services. Quality Improvement Organizations: Current Work. 2012. Available at: http://www.cms.gov/ Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityIm provementOrgs/Current.html. Accessed April 25, 2013. Medicare program: changes to the ambulatory surgical center payment system and CY 2009 payment rates: final rule November 18, 2008. Federal Register.73, (223), 68714. Available at: http://edocket.access. gpo.gov/2008/pdf/E8-26212.pdf. Accessed May 10, 2013. Cardo D, Dennehy PH, Halvserson P, et al. HAI Elimination White Paper Writing Group. Moving toward elimination of healthcare-associated infections: a call to action. Infect Control Hosp Epidemiol. 2010;31:1101–1105. National Institute for Health and Clinical Excellence (NICE). Infection, Prevention and Control of Healthcare-associated Infections in Primary and Community Care. London, UK: National Institute for Health and Clinical Excellence (NICE); 2012. 47 p. (Clinical guideline; no. 139). BMJ Quality & Safety. Knowledge for improvement, papers from the Vin McLoughlin Symposium on the Epistemology of Improving Health Care, UK, April 12-16, 2010. BMJ Qual Saf. 2011;20(S1):i1–i105. McNeil BJ. Hidden barriers to improvements in the quality of care. N Engl J Med. 2001;345:1612–1620. Lee GM, Kleinman K, Soumerai SB, et al. Effect of non payment for preventable infections in US hospitals. N Engl J Med. 2012;367:1428–1437. Lister J. On the Antiseptic Principle in the Practiceof Surgery. Br Med J 2. 1867;351:245–260. PMC 2310614. PMID20744875. Reprinted in Lister BJ. The classic: On the antisepticprinciple in the practice of surgery. 1867. Clin OrthoRel Res. 2010;468:2012–2016. Haley RW, Morgan WM, Culver DH, et al. Hospital infection control; recent progress and opportunities under prospective payment. Am J Infect Control. 1985;13:97–105.

www.lww-medicalcare.com |

S45

The national response for preventing healthcare-associated infections: infrastructure development.

The national response for preventing healthcare-associated infections: system capacity and sustainability for improvement.

Lessons learned and future directions: the national response for preventing healthcare-associated infections.

The national response for preventing healthcare-associated infections: data and monitoring.

Handwashing practices for the prevention of nosocomial infections.

Implementing AORN recommended practices for prevention of transmissible infections.

Adoption of obesity prevention policies and practices by Australian primary schools: 2006 to 2013.

Antibiotics for preventing meningococcal infections.

The National Diabetes Prevention Program: From Research to Reality.

A Collection on the prevention, diagnosis, and treatment of sexually transmitted infections: Call for research papers.

Promoting adoption of fall prevention measures among Latino workers and residential contractors: formative research findings.

Adoption of Evidence-Based Fall Prevention Practices in Primary Care for Older Adults with a History of Falls.

National Adoption Center: Open Records.

Preventing the voltage drop: keeping practice-based research network (PBRN) practices engaged in studies.

Preventing central line-associated bloodstream infections: a qualitative study of management practices.

Survey of infection control practices in hemodialysis units: preventing vascular access-associated bloodstream infections.

Evidence-based programming for adolescent HIV prevention and care: operational research to inform best practices.

A Swedish national adoption study of criminality.

Prevention of microbial hazard on fresh-cut lettuce through adoption of food safety and hygienic practices by lettuce farmers.

Emergency Department Central Line-associated Bloodstream Infections (CLABSI) Incidence in the Era of Prevention Practices.

Increased Health Information Technology Adoption and Use Among Small Primary Care Physician Practices Over Time: A National Cohort Study.

Current Concepts and Ongoing Research in the Prevention and Treatment of Open Fracture Infections.

A National Suicide Prevention Strategy for Canadians--From Research to Policy and Practice.

Behavioral and Social Sciences at the National Institutes of Health: adoption of research findings in health research and practice as a scientific priority.