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Jeff Brady, MD, MPH, director of the Center for Quality Improvement and Patient Safety at AHRQ and James Cleeman, MD, director of the Division of Healthcare-Associated Infections at the Center for Quality Improvement and Patient Safety, share their perspectives on the criticality of research to the pursuit of infection prevention and control.
Q: Although the medical literature has begun to address key issues in infection prevention and healthcare epidemiology, many more questions remain – what is your perspective on how important research is to this segment?
A: Research is vital to infection prevention. Healthcare-associated infections (HAIs) are among the leading threats to patient safety, affecting one out of every 25 hospital patients at any one time. Over a million HAIs occur across the U.S. healthcare system every year, leading to the loss of tens of thousands of lives and adding billions of dollars to healthcare costs. AHRQ funds HAI research to help clinicians and other healthcare staff prevent HAIs by improving how care is actually delivered to patients. This work is accomplished through investigator-initiated grants where researchers bring us ideas from the field that they think will solve a problem, and contracts that focus on this kind of research helping clinicians and staff better understand how to apply proven methods of making care safer. Our Comprehensive Unit-based Safety Program, or CUSP, illustrates AHRQ’s success in applying research to prevent infections. CUSP combines improvements in safety culture, teamwork, and communication together with a checklist of proven practices for preventing HAIs. CUSP started as an investigator-initiated research project led by patient safety expert Peter Pronovost, MD, who wanted to prevent patients from getting deadly central line-associated blood infections, or CLABSIs. AHRQ funded that research and continued to fund it because it was shown to be effective. Since its initial testing and implementation, CUSP has been implemented in more than 1,000 U.S. intensive care units, or ICUs. CUSP methods helped reduce bloodstream infections by 41 percent, prevented over 2,100 CLABSI cases, saved more than 500 lives, and avoided more than $36 million in excess costs. To help other ICUs apply this knowledge, we created online tools that can be easily downloaded for free and adapted to suit local needs. AHRQ has successfully applied CUSP to the prevention of other HAIs in other settings. AHRQ’s nationwide CUSP projects have reduced rates of CAUTI in hospital non-ICUs by 30 percent, CAUTI in nursing homes by 54 percent, and SSI in hospitals by 25 percent to 40 percent.
Q: What are the key issues relating to patient safety and healthcare quality/infection prevention that remain unresolved or need further research?
A: AHRQ’s funding programs are designed to address some of the key issues in patient safety and infection prevention, such as combating antibiotic resistance. Emerging infections are a serious threat to patients and our health care system. Particularly alarming is the emergence of infections caused by bacteria that are resistant to most or all life-saving antibiotics. We are currently funding research to develop better methods and tools that will help physicians and nurses combat antibiotic resistance and improve antibiotic use. At an even broader level, much of the work that AHRQ does has an impact on antibiotic resistance. Every infection prevented is one less episode of antibiotic use and one less opportunity for resistance to develop. Preventing these infections in the first place is a critical aspect of AHRQ’s HAI research – and that’s a primary way to keep patients safe from harm and reduce the need for antibiotics. In addition to infection prevention, diagnostic error is a significant and under-recognized threat to patient safety. AHRQ is funding research to better understand how these errors happen and what can be done to prevent them. We held a Diagnostic Safety Summit in 2016 where we began to explore definitions of the term “diagnostic safety,” why errors happen, and how we can keep them from happening. While these are the questions we are just beginning to answer, we are naturally drawn and committed to the priority of improving diagnosis.
Q: What kinds of studies are most effective for accelerating research in infection prevention and healthcare epidemiology?
A: We do know that randomized controlled trials can be expensive and time-consuming. We also know that evidence from randomized control trials must be integrated into the care delivered to patients to put it to use. AHRQ’s support for studies of implementation science helps clinicians understand how to do that. The agency invests in research aimed helping clinicians and health systems progress from the "what" to the "how" of making healthcare safer and higher quality. As mentioned earlier, CUSP is a prime example of this transfer of evidence into practice. In addition to clinical trials, evidence useful for guiding practice may be derived from large databases of patient encounters in healthcare systems. A clinical trial may often be needed to transform this information into conclusive evidence for improving care and outcomes. More good examples of AHRQ researching being applied to practice can be found with our patient safety learning labs. Funded by competitive grants, these projects bring together experts from multiple disciplines to identify, research and build solutions to complex patient safety challenges, with a focus on the physical environment, technology, and clinical workflow processes. For example, the team at Clemson University and Medical University of South Carolina designed a new operating room prototype that includes numerous practical safety improvements. The innovations include improving staff safety by reducing clutter and trip hazards; reducing surface contamination through material selection and ergonomics; supporting team communication by refining sightlines and visibility; and using modular wall panels that allow for adaptations as care delivery and technology change. These projects are using systems engineering approaches to solve many different patient safety challenges.
Q: On that note, is some research -- despite it being inferior -- better than no research, when it comes to implementing practices based on the findings in the medical literature?
A: AHRQ seeks to help clinicians use available evidence, which may be scattered and incomplete, by synthesizing that knowledge into evidence reviews which are more applicable to everyday practice. AHRQ’s Evidence-Based Practice Centers and Effective Health Care Program do this well. These programs have researchers who review the available evidence on the effectiveness of treatments, while also identifying potential harms. These evidence reviews play a role when it comes to evaluating the quality of evidence, providing clinicians with evidence-based information on common, costly medical conditions, treatments, and new health care technologies and strategies. Our AHRQ Patient Safety Network, or PSNet, is one way for clinicians to stay up-to-date on the latest research and evidence on patient safety. It serves as a timely digest of current patient safety findings and how they may be implemented. It also provides resources for self-education for those new to patient safety concepts. As we know, the evidence base is growing all the time, so there is an ongoing need for these functions.
Q: How should data from research studies be interpreted at the bedside? What kind of critical thinking skills do clinicians need to be more discerning when wading through an ocean of research, both optimal and inferior?
A: Clinicians work hard to keep up with the latest journal articles and fulfill requirements for continuing education. But it’s a tall order for anyone to keep current on the never-ending flow of information from new research. The ability to distinguish the results of a solitary trial from the overall pattern of evidence is a crucial skill. Developing this skill begins with medical education and training and extends to continuing medical education. In addition, AHRQ has been exploring the benefits of learning health systems, which have the potential to collect, adopt, and apply evidence. At their core, learning health systems are committed to improving patient care in a systematic and cyclical way: analyzing internal and external clinical data, creating knowledge; knowledge informs clinical practice; that clinical practice creates new data, which are analyzed; and the cycle starts all over again. Simply put, learning health systems collect, adopt, and apply evidence in a systematic way. These systems provide an environment to help clinicians apply the evidence. It’s that deliberate and methodical way of integrating new data and evidence into the care process that sets learning health systems apart. The potential is enormous for helping clinicians access the best evidence and improve patient care.