By Kelly M. Pyrek
Editor's note: In the July 2010 issue of ICT, we first explored the growing importance of the implementation science movement. Here, we provide an update on the role that infection preventionists can play in the dissemination and implementation science process.
Knowing that research drives practice, which then impacts patient outcomes, the infection prevention and healthcare epidemiology is striving to improve its embrace of implementation science (defined by Eccles and Mittman as "the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice"). Although federal agencies and professional societies have been churning out guidelines and standards for decades, practitioners have been struggling with what should inform daily practice and how the evidence should become accepted practice.
In a recent Safe Healthcare blog hosted by the CDC’s Division of Healthcare Quality Promotion, Russell N. Olmsted, MPH, CIC, the 2011 president of the Association of Professionals in Infection Control and Epidemiology (APIC), muses, "Infection preventionists (IPs) are subject matter experts on the prevention of healthcare-associated infections (HAIs). IPs track the scientific literature related to HAI prevention, and then watch that evidence as it is distilled into recommendations by CDC’s Healthcare Infection Control Practices Advisory Committee. But what is being done to ensure that these best practices are being implemented at the patient bedside?"
Olmsted says that the IP must take on the role of an "effector" in order to apply the recommendations to his/her healthcare organization in collaboration with healthcare workers who engage in direct patient care, adding that, "…We are typically the 'linchpins' of applying research that appears in scientific, peer-reviewed journals to policies and practices implemented by our colleagues at the patient’s bedside."
It's a tall order for infection preventionists to be able to locate, absorb and synthesize the abundant amount of information contained in the medical literature while simultaneously performing one's daily tasks. It can be equally challenging to achieve adoption of best practices. As Olmsted notes, "Many of us know that the speed of adopting new findings in the literature to improving the safety of care delivery can be exceedingly slow. For example, a landmark study published in The Lancet in 1991 demonstrated the superior efficacy of 2 percent chlorhexidine for skin preparation prior to insertion of central lines. And yet, 14 years later, only 70 percent of hospitals in a national survey were using this product."
These challenges are among the impetus for APIC to help practitioners identify and prioritize research priorities. Olmsted points to how APIC’s Research Task Force recently reviewed the role of the IP in translating scientific evidence to improve patient safety and effectiveness of care, and emphasizes that "the goal of implementation science is not only to raise awareness but to also use strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings."
In January 2010, APIC‘s board of directors decided to update and clarify the association’s approach to research. The efforts of the APIC’s Research Task Force were chronicled in a paper by Patricia Stone, RN, PhD, FAAN, and colleagues in the American Journal of Infection Control (AJIC) which also reviews the history of APIC’s role in research and reports on the recent vision and direction developed by a multi-disciplinary task force regarding appropriate research roles and contributions for APIC and its members. Stone, et al. (2010) assert that dissemination and implementation science, a type of research aimed at understanding how to translate research evidence into practice, must increasingly become one of infection prevention's core areas of expertise, and that this is an area in which APIC members can apply their unique skills and competencies to ensure that patients receive the most up-to-date and evidence-based infection prevention practices possible.
APIC's research agenda achieved more clarity in 2000 when the APIC Research Foundation funded and conducted a Delphi process that identified 21 research priorities that could be used as rationale and supporting evidence for the need for research funded by other organizations. As Stone, et al. (2010) explain, "At that time the highest ranked research priorities were related to obtaining evidence on how best to improve compliance with best practices, use antimicrobials appropriately and decrease resistance, measure the financial impact of complications of HAI and value of interventions aimed at preventing HAIs, perform surveillance of infectious and noninfectious complications across the spectrum of care delivery, and prevent complications at specific sites (e.g., ventilator-associated pneumonia)."
Stone, et al. (2010) acknowledge that while APIC is not the sole arbiter of the infection prevention research agenda, the association and its membership "should continue to inform and guide the type of research that is conducted by developing an up-to-date research agenda that is regularly reviewed to ensure its ongoing value and fit with member needs and the external public policy, practice, scientific, and biologic environments." Although the APIC Research Foundation eventually evolved into the Scientific Research Council, APIC continues its research efforts, including overseeing several recent major research studies on MRSA and C. difficile prevalence, as well as other partnerships with faculty from Columbia University and Harvard University in which APIC staff and members had input into developing the research design, recruitment, and/or dissemination of results.
As APIC grows its research agenda, there is a role that infection preventionist can play in the process. While these practitioners will find themselves at very different points along the research spectrum, the important consideration is that they understand the goals and processes involved in implementation science.
Stone, et al. (2010) acknowledge that not all infection preventionists will be able to become researchers: "The primary role of most of APIC’s members is in the clinical setting as IPs. It is likely their major contribution to research may be participating in research led by others and implementing research findings as well as identifying gaps in knowledge and setting research priorities."
"People play different roles in research," Stone says. "Not everyone is inclined to be a researcher, even though we do need more researchers. Clinicians might not want to develop their own research proposals, but they can participate in research in very appropriate and meaningful ways. One way is through participating in dissemination and implementation science, which is a different type of research -- it's not as controlled and the goal is to see if the evidence from studies works in everyday practice. Many more different studies are needed to eventually lead practice. There might already be some evidence that it works in a lab or a similarly controlled setting, but then you must determine how you can fit this evidence into everyday practice. That's the current movement toward dissemination and implementation science not only in infection prevention and control but across the healthcare spectrum."
Knowing that levels of engagement with research are going to be different depending on the individual, Stone encourages infection preventionists to at least become familiar with the basics of understanding the medical literature, knowing that being able to implement the best quality of care is usually based on what is contained in the research. "We all have a responsibility to understand the research, to understand scientific journal articles and know whether they are applicable or not to our practice," Stone says. "The hope is that infection preventionists and others will participate in research but I don't think every clinician needs to know how to design and conduct a research study. They should understand whether or not the basic design of the study is strong and know whether they want to implement the results or participate in the research, so they must have that basic knowledge. At the very least, I think all infection preventionists must try to implement the very best research into their own practices, and conduct their own analysis of how it's working in their own setting."
Stone says there are resources available from APIC and elsewhere to help infection preventionists understand evidence-based practices and how to access the clinical evidence. "It's advisable to refresh yourself on how to read and understand a study," Stone says. "There is some effort currently to try to eliminate the confusing words in the research vernacular and to make it more accessible to everyone, but it helps to also be part of a larger group -- whether it's through an APIC chapter or through a local organization, club or society -- that can help you understand the literature. I think a strategy such as developing or joining a journal club in your setting is very important. In a journal club, everyone reads the same paper and then they discuss it."
Stone adds that infection preventionist also must be able to differentiate research projects from quality improvement projects. "Quality improvement and research can look similar but there are differences," Stone explains. "Research will be conducted with the idea of developing generalized knowledge for others, whereas if it's a quality improvement initiative within your own facility, you are trying to understand what works in your own setting, but not trying to inform the whole practice."
Regardless of whether they conduct or participate in the research, infection preventionists must understand the basic tenets of dissemination and implementation science. As Stone et al. (2010) explain. "…dissemination is the targeted distribution of information and intervention materials to a specific audience. Implementation implies that the goal of the communication is, however, to do more than increase awareness; it is the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings. Dissemination and implementation science has been defined as research that creates new knowledge about how best to design, implement, and evaluate quality improvement initiatives." Stone et al. (2010) explain further that the need for dissemination and implementation science "grew out of the reality that, even when new knowledge is discovered and adequate research is available, there are many barriers to translating research into practice. In the absence of effective implementation and evaluation, even the best research findings are only theoretical."
Stone et al. (2010) say that because infection preventionists must set and recommend policies and procedures in relation to prevention and control of infections based on the best evidence available, they must cultivate the ability to evaluate the methodologic rigor and quality of published studies, and add, "Other tangential skills include formulation of key clinical questions, searching the literature and applying findings to improve safety and quality of care. There is evidence that these skills along with certification in infection control and epidemiology correlate with more efficient and effective use of evidence to improve practice and prevent HAIs."
