By Kelly M. Pyrek
The 2011 annual scientific meeting of the Society for Healthcare Epidemiology of America (SHEA), held the first week in April in Dallas, brought together a diverse group of experts in healthcare epidemiology, infection prevention and public health to address the most pressing issues related to patient safety. What follows are some of the highlights of the meeting's plenary sessions.
The opening plenary session, "Innovative Public Policy to Prevent HAIs," addressed the rapidly evolving public policy-driven approaches that are driving infection prevention and control and which are moving beyond mandates for public reporting of infections and pathogen-specific surveillance. Government, business and healthcare stakeholders are pushing for policy innovations in reimbursement, quality improvement and measurement, as well as in behavioral change and implementation. The session outlined key policy initiatives of the Centers for Medicare and Medicaid Services (CMS) and efforts to evaluate the impact of policies and measure progress toward preventing healthcare-associated infections (HAIs).
In his presentation, Joseph McCannon from CMS acknowledged that while the agency is often viewed as "an organization that happens to people," it is seeking to deepen its understanding of infection prevention and healthcare epidemiology, advance its partnership with these stakeholders, and improve the function of CMS as a driver of system improvements. McCannon explained that there are a number of CMS levers for building the will to reduce HAIs, including establishing conditions of participation and coverage for its beneficiaries, as well as public reporting of infections and the survey and certification process. McCannon added that key considerations for the agency in the future include thoughtful creation of tension for change in order to build the will to fight HAIs; demonstration of alternatives to encourage continued innovation; and support for the execution of the aforementioned change and innovation.
"I echo the sentiment of Don Berwick who said that 'Making people afraid doesn't make them able,'" remarked McCannon, who added that CMS hopes to help organizations in the united effort to uphold patient safety.
As part of the public policy plenary session, Chesley Richards, MD, from the Centers for Disease Control and Prevention (CDC), shared key points about HAIs relating to lessons learned from public health, including the need to stay relentlessly focused; have actionable data; uphold science-based interventions; use effective policy-based levers; and seek public support.
Also part of this plenary session, Patricia Stone, RN, PhD, MPH, from Columbia University School of Nursing, reviewed the reputational, financial and spending levers associated with national HAI-related policy, as well as reviewed the history of public reporting of infections. She noted the vexing variation in state reporting laws, including length of time, the number and types of infections, process measures and the tension between public reporting and public health reporting. She emphasized that the goal must be safe, effective, patient-centered care, as noted in the Institute of Medicine's "Crossing the Quality Chasm" report, and that public reporting must be subverted to that mandate as well as serve as a useful tool to produce meaningful data. "We need more evidence-based policy-making," Stone said.
And finally, panelist Patrick J. Brennan, MD, of the University of Pennsylvania Health System and chair of the SHEA public policy committee, reviewed the drivers of public dialogue about HAIs, including payors, consumer groups, the media, accreditation bodies, non-profits, industry and professional societies. Brennan emphasized that the evolving healthcare landscape required "new" core competencies such as physician integration, care coordination, cost management, better information systems, better payor relationships, increased financial capacity and the necessary capital to scale to market needs.
Brennan also addressed SHEA's growing presence in the implementation science movement with the creation last year of its research collaborative. He noted SHEA's hypothesis that research science would translate into guidance development, which would then create better advocacy with policymakers, which would trigger policy adoption, which would then result in better patient outcomes overall. He also reviewed SHEA's strategic plan, released last October, and noted that SHEA was emphasizing core competencies including increased expertise and research, partnership development, access to policymakers, the creation of educational tools, the partnership with media members, and the alignment of interests with key regulators and decision-makers.
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The plenary session, "Translating Mandates, Guidelines and Bundles Into Practice: Lessons From Implementation Science" featured insights from implementation science that can make HAI prevention more effective, consistent and rapid. Panelists addressed the role of leadership in implementing change, bundling interventions and scaling them across healthcare institutions and networks, as well as the role of human factors and systems engineering in facilitating and sustaining these improvements.
Sanjay Saint, MD, MPH, of the University of Michigan and Ann Arbor VA Medical Center, emphasized the importance of good "leadership and followership" in the quest to curtail and eliminate infections. He explained that infection prevention is an excellent model for understanding implementation success and failure, and that it's critical to understand that the variability of success is related to the kinds of people who work in healthcare organizations. Saint said that the key barriers to implementing evidence-based practices are several archetypes of healthcare professionals:
- The active resisters do things the way they have always done them and resist change. The way to disarm them is to use data to show them the need for change as well as get buy-in from a "member of their tribe" to help persuade for change.
- The organizational constipators are the passive-aggressive individuals who undermine change without active resistance. The way to disarm them is to apply leadership at all levels in the organization across all disciplines.
Saint emphasized that effective infection prevention leaders have four key behaviors: they cultivate clinical evidence; they inspire staff members; they are solution-oriented; and they think strategically while acting locally to solve problems.
While technical implementation science is a major driver (which includes randomized controlled trials, hard data and evidence), Saint added that a socio-adaptive approach was also needed that accounted for human behavior. Saint suggested that infection preventionists and healthcare epidemiologists needed to move beyond traditional training to do their jobs and include more elements of implementation science, human factors engineering, and organizational behavior that actively engages healthcare leaders and followers.
In the same plenary session, Carla Alvarado, PhD, from the Center for Quality and Productivity Improvement, discussed human factors engineering -- essentially meaning designing the work to fit the individual -- in the context of infection prevention. Alvarado said that the current reality of infection prevention is "more isolation than integration" and that the field suffers from a lack of learning systems and authority, a poor understanding of the economics of HAIs, and that infection preventionists can sometimes be "more cop than coach." When it comes to human factors engineering, infection prevention and a simple task such as hand hygiene, Alvarado says, "We are an interruption to what healthcare workers think their tasks are." In other words, Alvarado explained that infection prevention is targeted at individual change, but that what is needed is systemic change through human factors engineering. Going back to the hand hygiene example, Alvarado explained that healthcare workers tend to see infection prevention practices as mere interruptions to the "real" tasks at hand, and that infection preventionists must incorporate these practices into other tasks so that something such as hand hygiene is no longer seen as a standalone task. Alvarado says that it can get lost in the noise of a complex healthcare system, so hand hygiene or any other evidence-based practice must be embedded into the "real" tasks as perceived by busy healthcare workers.
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This year's SHEA Lectureship was delivered by Victoria Fraser, MD, of Washington University School of Medicine, who spoke on the topic of "Leveraging New Healthcare Trends and Research Tools for HAI Prevention." Fraser addressed key elements of healthcare reform and the growing emphasis on comparative effectiveness research that are opening new avenues for understanding and addressing HAIs. In 2011, the current landscape for infection prevention and healthcare epidemiology is fraught with complications, including greater scrutiny, higher expectations to eliminate HAIs, increased measures to follow, an expanding scope of work, financial challenges and the need for system changes in healthcare, Fraser said. The good news, Fraser emphasized, is that now -- as opposed to decades ago -- there are many more individuals and entities standing alongside infection preventionists and hospital epidemiologists in the fight against HAIs; however, the challenge is that because of the variability in standards and definitions, a great deal of disparate data is being generated.
New infusions of cash, such as from the Recovery Act spending, will help the field tackle the rigors of comparative effectiveness research (CER), the newest term for evidence-based medicine, Fraser added. She explained that CER attempts to identify the very best systems and interventions for patient-focused outcomes. The tier 1 national priorities for CER currently include strategies to reduce and eliminate HAIs, CLABSIs, VAP and SSIs, as well as eradication of MRSA colonization and infections in healthcare facilities and in communities. Other key efforts are being undertaken by the AHRQ, the CDC and the Joint Commission, among others, and Fraser encouraged healthcare epidemiologists to work with these agencies to ensure high levels of evidence generation and evidence translation. Fraser also recommended that epidemiologists acquaint themselves with the Patient Centered Outcomes Research Institute (PCORI), which was established by the Patient Protection and Affordability Act of 2010. With sustainable funding of $650 million, PCORI is overseeing CER funding and its goal is to disseminate research findings for translation into healthcare practice.
For the future, Fraser said that there must be a change from a descriptive approach to an interventional approach, and that more research must be translated into practice. Additionally, she said that suboptimal infection prevention practices must be addressed and that the next tier of multidrug-resistant organism (MDRO) management must be reached.
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In a lively debate that involved attendee participation, experts explored "Strategies to Prevent HAIs: Targeting High-Risk Patient Populations vs. High-Risk Pathogens." Taking the assertion that "Pathogen-Directed Interventions are Necessary for Optimum Control of Healthcare-Associated Infections" was John Jernigan, MD, of the CDC, who explained that pathogen-directed interventions were a "vertical" approach designed to prevent transmission of infection by a specific pathogen. Jernigan said that the traditional "horizontal" approach of non pathogen-directed interventions (such as standard precautions, hand hygiene and environmental cleaning, etc.) must be supplemented by the vertical approach, and added that "Pathogens definitely matter when designing an optimal infection prevention program" and that these pathogens dictate interventions because "one size does not fit all."
Jernigan also said that infection preventionists and healthcare epidemiologists must take into consideration the level of transmissibility,, the mode of transmission, and the consequences of infection, before automatically assigning a horizontal approach to the infections at hand. He also questioned the effectiveness of current horizontal interventions, the lack of resources available to make these horizontal interventions feasible, and the epidemiology of the pathogen is what should dictate interventions.
Arguing that "Pathogen-Directed Interventions are Not Necessary for Optimum Control of Healthcare-Associated Infections" was Anthony Harris, MD, of the University of Maryland School of Medicine, who acknowledged the rationale behind horizontal interventions -- that less acquisition of resistant and susceptible pathogens may translate into less contamination and fewer infections -- and emphasized that these practices were efficacious and cost-effective, and potentially addressed the widest number of potential infections. He added that the SHEA guidelines recommend non pathogen-directed interventions, and that these practices remove more problematic pathogens than vertical approaches such as active surveillance.
Both Jernigan and Harris acknowledged that a combination of the two approaches made sense, as did a greater emphasis on the setting in which infections occur and pathogens are present -- the approaches used for a burn unit, for example, would be much different than for a general hospital unit. Harris added that the goal should be engaging in research that proves horizontal or vertical approaches work, and that researchers continue to think of ways to make all of these strategies more effective at eradicating pathogens and reducing infections.