IPs Sharpen Critical Thinking Skills as They Evaluate the Evidence Behind Common Interventions

By Kelly M. Pyrek

Infection preventionists are helping to determine which practices make it to the bedside, a critical component of this diffusion of evidence is called implementation science. A recent study revealed that there is general agreement among hospital-based IPs in regard to which interventions have weak or strong evidence supporting their use to prevent healthcare-associated infection.

The study, published in the February 2013 issue of the American Journal of Infection Control, was conducted by a research team led by Sanjay Saint, MD, MPH, of the VA Ann Arbor and University of Michigan Medical School. The researchers collected survey responses from infection prevention personnel at 478 U.S. hospitals to determine the perceived strength of evidence behind 28 of the most common infection prevention practices aimed at preventing device- and procedure-associated infections and lessening the risk of cross-transmission of microorganisms in healthcare facilities.

Co-author Russell N. Olmsted, MPH, CIC, director of infection prevention and control services at Saint Joseph Mercy Health System in Ann Arbor, Mich. explains that their project was a repeat of an initial survey conducted in 2005 of lead IPs in a random sample of hospitals across the U.S. and a 100 percent sampling of VA medical centers. "We looked at the diffusion across a wide range of acute-care settings, focusing on device-associated infections and which prevention practices are making it to the bedside," says Olmsted. "We wanted to know if IPs using the scientific evidence as it appears and then applying it to patient care."

Practices perceived by 90 percent or more of the respondents as having strong evidence to support their use included alcohol-based handrub, aseptic urinary catheter insertion, chlorhexidine for antisepsis prior to central venous catheter insertion, maximum sterile barriers during central venous catheter insertion, avoiding the femoral site for central venous catheter insertion, and semi-recumbent positioning of patients on ventilators. Conversely, practices with the weakest perceived evidence were routine central catheter changes, using silver-coated endotracheal tubes for ventilator-associated pneumonia (VAP), nitrofurazone-releasing urinary catheters, and the use antimicrobials in the urinary catheter drainage bag.

According to Saint, The perceived strength of evidence among infection prevention personnel across the country generally tracked with the actual strength of the evidence for various practices that have been reported in evidence-based guidelines.
"After reviewing the results the question is, do perceptions by IPs reflect reality (adoption of evidence-based interventions) or do these perceptions reflect what practices are in place to prevent HAIs?" asks Olmsted, who, along with his co-authors, pondered how those who might champion HAI prevention activities in the hospital view the recommendations that are being provided. As the authors explain, "For instance, if a practice is perceived as being supported by weak evidence by those in a position to affect change among front-line healthcare personnel, uptake and implementation of this practice is unlikely irrespective of the underlying strength of the evidence ... IPs are not only expected to keep up with the prevention literature and make recommendations as to what practices to use to prevent infection, they may lead hospital efforts to implement the practice for routine use by front-line healthcare personnel. In this manner, IPs are a key link in the diffusion of innovation process by taking recommendations from the scientific literature and implementing certain recommendations in their facility."

"Some of the results clearly make a lot of sense, but some things surprised us," Olmsted adds. "For example, regarding the strength of evidence for general practices, antimicrobial stewardship resonated very strongly with IPs, however at the time of sampling in 2009 there weren't a ton of randomized controlled trials showing that antimicrobial stewardship improved patient safety. There were some good studies, but I was a little surprised by how well that resonated. If you fast-forward to 2013 it's clear that IPs do inform stewardship and vice versa, but at the time of the study it wasn't as high-profile or as robust. This finding  is important because most of the problems we have with Clostridium difficile, for example, is inappropriate antibiotic use. I think that message has gotten to IPs."

Let's take a closer look at the results of the study.

General infection prevention practices
According to Saint, et al. (2013), "Nearly all respondents believe that hand hygiene with alcohol-based handwash has strong evidence to support its use. Antimicrobial stewardship programs also were perceived as having strong or moderate evidence supporting their use by 97 percent of respondents. Support for infection prevention practices focusing on preventing methicillin-resistant Staphylococcus aureus had more modest support."

"Active surveillance for MRSA has been a topic of controversy and I think the results reflected that," says Olmsted. "There are two major studies that reached opposite conclusions. This 'scientific dissonance' likely influenced perceptions and practices recommended by IPs. By contrast, consistent positive findings of efficacy of chlorhexidine for skin antisepsis to prevent CLABSI was reflected in responses to this survey -- strong perception and a high level of adoption.

CAUTI prevention practices
According to Saint, et al. (2013), among practices to prevent CAUTI, respondents believed the evidence supporting aseptic insertion technique was the strongest, followed by timely removal of the urinary catheter (utilizing either a urinary catheter reminder or stop order) or a nurse-initiated removal protocol. Bladder ultrasound scanning also was perceived as having reasonably strong supporting evidence, as was the use of intermittent catheterization. The perceived strength of evidence supporting condom catheters in men and antimicrobial urinary catheters, on the other hand, was much lower."

"Inserting the urinary catheter aseptically makes sense intuitively but there is not much data," Olmsted says. "It's a bit of a contrast between what we perceive as well supported evidence versus the reality. One interesting aspect of our study is there are two antimicrobial central venous catheters on the market and the studies for both contain good evidence; however, IPs didn't view it as strongly as the studies would suggest. What may be influencing that is the emphasis on the central line insertion bundle;  I suspect most IPs saw a dramatic impact from applying those key measures in the bundle.  By applying basic interventions, they saw a dramatic drop in the frequency of CLABSI and they probably felt that because these interventions take care of the majority of infections, then they may not have a cost-effective basis to move toward antimicrobial technologies. Everyone would probably like to use them but it's the challenge of doing that with limited resources."

CLABSI prevention practices
According to Saint, et al. (2013), "Among respondents, 90 percent or more IPs perceived the strength of evidence supporting the following practices as strong: chlorhexidine gluconate for insertion site skin antisepsis, maximum sterile barriers during CVC insertion, and avoiding the femoral site for central venous catheterization. The perceived strength of evidence supporting the use of chlorhexidine sponge dressings at site of CVC insertion was less strong. The evidence supporting the use of antimicrobial catheters was perceived as moderate. Routine CVC changes were perceived as having weak evidence." The authors explain further, "Regarding CLABSI, the 2011 updated HICPAC Guidelines for the Prevention of Intravascular Catheter-Related Infections highlight evidence-based practices proven to decrease the risk of this adverse outcome. Importantly, the guidelines endorse the performance of specific practices in tandem (or bundling) as a vehicle for reducing the burden of this HAI. In our survey, we found that most respondents correctly recognized elements comprising the CLABSI bundle (eg, hand hygiene by the provider prior to insertion, use of maximal sterile barrier precautions, chlorhexidine for skin antisepsis, and avoidance of the femoral vein for site of insertion) as being supported by strong evidence. However, we found some important variations. For example, about one-third of respondents indicated that routine CVC changes had moderate or strong evidence supporting its use. On the contrary, several randomized trials have found this practice not to be beneficial. In fact, routine changes over guidewires have been associated with a trend toward increased risk of CLABSI."

VAP prevention practices
According to Saint, et al. (2013), "Semi-recumbent positioning was perceived as having strong evidence for preventing VAP by 97 percent of respondents, followed by 'sedation vacation' (88 percent), antimicrobial mouth rinse (68 percent), and subglottic secretion drainage (59 percent). Other practices such as oscillating/kinetic beds, topical and/or systemic antibiotics for selective digestive tract decontamination, and silver-coated endotracheal tubes were perceived as having less strength of evidence." The authors explain further, " The finding that the silver-coated endotracheal tubes were perceived to have the weakest strength of evidence supporting their use may also stem from the fact that the study results assessing the efficacy of the silver-coated tube were reported after the publication of the guideline. Importantly, the evidence base supporting VAP preventive practices appears to be substantially less robust than that for CLABSI as highlighted in a recent article."

"The antimicrobial mouth rinse, which intuitively makes sense, jumped out at me when looking at these results albeit the strength of this intervention is not as robust nor generalizable as the perceptions identified," Olmsted says. "And regarding the silver-coated endotracheal tube, there was a well-done study showing a significant drop in the risk of VAP. For any device that resides in a patient for even the smallest amount of time, it may make sense if we can introduce some antimicrobials to that device surface. However, clearly people have had a lot of success with routine strategies before going to the next level of antimicrobial devices."

Implementation Science
In 2011, in a Safe Healthcare blog hosted by the CDCs Division of Healthcare Quality Promotion, Olmsted observed, "Infection preventionists 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 CDCs 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 patients 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 their 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 APICs 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, APICs board of directors decided to update and clarify the associations approach to research. The efforts of the APICs 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 APICs 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.

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."

Olmsted says their recent study demonstrates that most IPs are consumers of the peer-reviewed literature. "There are a fair number of IPs who are involved in active research projects, which is great and APIC encourages that, but we realize that probably most of our members are consumers of published research instead. So we built implementation science into our new core competency model."

In APIC's core competency model, the implementation science goal is to promote and facilitate the development and implementation of scientific research to prevent infection. According to APIC, IPs should be able to accomplish the following:
- Define implementation science (IS) and demonstrate the value of implementing the science of prevention to members, partners, and stakeholders.
- Identify gaps in the research agenda and address the gaps.
- Collaborate with related disciplines and organizations in promoting implementation science research

With this core competency, it is hoped that a greater number of IPs and their hospital colleagues will be able to submit well-designed scientific abstracts and papers; that they will be able to make presentations at the APIC annual conference and other meetings that demonstrate use of implementation science; that they will be able to publish whitepapers on gaps in the current research agenda as well as submit papers to peer-reviewed journals at increased level

"An element we are working on with our members is to enhance their critical review of the literature, which is a key skill for IPs," says Olmsted. "Many IPs need to improve their skills and there are some good criteria that they can apply to studies to give them an idea of how strong the study findings are;  one of these involve use of the grade system, as described by Dr. Craig Umscheid who assisted HICPAC with the use of this to create recommendations in their guidelines. For example, if it's a study of only five patients, that goes way down the list in terms of rigor and strength; however, if it's a multicenter randomized controlled trial, that is so much more robust. We hope that IPs enhance their abilities to evaluate studies in the literature and pick out the right signals amidst all the noise."

Olmsted says the results of their project can help emphasize to researchers the need for well-designed studies to better inform infection prevention practice.  "Basic research is important because it's a building block for more advanced translational research," he says. "But we also need to be building on that foundation of basic research so that it leads us in key directions and helps us adopt evidence-based practices more widely. For researchers, strong methodology in their studies is probably the most important element, as  we want results that come out of an investigation to give us a good idea of whether the strategy worked or not. By going to conferences and hearing poster presentations and oral abstracts, IPs are getting a sense of those early investigations; these IPs are picking up on cutting-edge interventions that are a little ahead of the adoption curve. I think many of them are looking ahead to the next strategy with which to address infections."

A common frustration with implementation science is the lag between the research and actual publication of guidelines that recommend this aforementioned evidence-based research. "The incubation period for the CAUTI guidelines was a long time, for example," says Olmsted. "The maturation process for a guideline is longer than I would like, and the problem is as soon as that guideline comes out, the studies that served as the foundation for the recommendations are a few years or more behind. To bridge that gap a bit would be things like APIC's updated Implementation Guides to give IPs the proven tools and techniques, while leaving the door open to newer findings in the literature. We encourage IPs to take a look at the literature fairly often to see what is new for a particular intervention. If they assess the strength of those studies using an objective scoring tool, they can see if this is something they want to implement sooner rather than later, instead of simply waiting for a guideline to be issued."

With great strength in the technical domain and in the infection prevention and control domains of APIC's core competencies model, IPs continue to sharpen their critical thinking skills in the performance improvement and implementation science domains. Olmsted says he encourages them to make strides in leadership and program management. "They can be the most transformative elements of infection prevention," he says. "We must make sure we engage colleagues and other stakeholders with key strategies. When you look at the Keystone Project, it showed how socio-adaptive elements of behavior change are important. we have good evidence that if we can get direct-care providers to use these tools and strategies consistently, they can really improve patient safety.  It's the culture of safety that IPs must continue to embrace. The social science piece of infection prevention involves an array of practices that can help move healthcare providers toward adoption. It's getting those groups to work as a team that is an essential ingredient. If IPs can bring scientific studies to these forums, there is a good proportion of stakeholders that will respond to that information."

Certification of Infection Preventionists
It would appear that certification in infection control can aid IPs in evaluating the strength of the evidence. Furthermore, IPs with certification in infection prevention and control (CIC®) are two to three times more likely to perceive the evidence behind certain infection prevention practices as strong, compared to their non-certified peers. The research team further examined the perceptions of evidence supporting practice use between certified and non-certified IPs. Compared to their non-certified counterparts, certified IPs were more likely to perceive the strength of evidence as strong for a number of infection prevention practices including: regular interruption of sedation for VAP patients, nurse-initiated urinary catheter discontinuation to prevent catheter-associated urinary tract infection, and antimicrobial stewardship programs.

Saint, et al. (2013) report that having an IP with a certified in infection control (CIC) credential "was associated with a two-fold increase in the odds of reporting strong perception of the evidence for antimicrobial stewardship programs. Furthermore, several significant associations were found between CIC status and perceived strength of evidence for device-specific HAIs. Within CAUTI, CIC status was associated with a two-fold increase in the odds of reporting strong perception of evidence for nurse-initiated urinary catheter discontinuation protocols. Among CLABSI prevention activities, having an IP CIC was associated with approximately a 40 percent decreased odds of reporting strong perception of evidence for routine CVC changes. Finally, within VAP prevention, having an IP CIC was associated with approximately a 45 percent and 55 percent decreased odds of reporting strong perception of evidence for oscillating/kinetic beds (P ¼ .002) and for antimicrobial mouth rinse, respectively. CIC status was also associated with nearly a three-fold increase in the odds of reporting strong perception of evidence for 'sedation vacation.'"

"The gratifying piece to this investigation was the correlation between certification and infection prevention," says Olmsted. They are subject-matter experts in their facilities and they taking that evidence and putting it into practice. Understanding the impact of board certification on the effectiveness of an infection prevention program is imperative. This study adds to mounting evidence that suggests that CIC may lead to greater evidence-based practice, which may result in the reduction of both healthcare-associated infections and hospital costs.

Certification in infection prevention and control (CIC) is the centerpiece of a new competency model developed by APIC to advance the profession. The content areas of the model correspond to the core competencies as defined by the Certification Board of Infection Control and Epidemiology (CBIC). APIC's goal is to define, develop, strengthen and sustain competencies of the IP across the career span and support board certification in infection prevention and control to obtain widespread adoption. The organization also wants to have at least 50 percent of its eligible APIC members be CIC-credentialed.

Reference: Saint S, Greene MT, Olmsted RN, Chopra V, Meddings J, Safdar N and Krein SL Perceived strength of evidence supporting best practices to prevent healthcare-associated infection: Results from a national survey of infection prevention personnel. American Journal of Infection Control. Vol. 41, No. 2. February 2013.