BACKGROUND/RATIONALE:
Disseminating sound scientific evidence, once it is established, is a fundamental part of promoting high quality care and a safe health care environment. However, determining the best methods for ensuring the effective use of proven practices in real world clinical settings is a challenging task.
OBJECTIVE(S):
The overarching objective of this research is to identify and develop strategies to optimize the successful implementation of key practices in the field of patient safety and health care associated infection prevention. The primary aims of this study were: 1) To describe the adoption and diffusion of evidence-based infection prevention practices among VA medical centers; and, 2) To identify and compare factors that facilitate and impede the adoption and implementation of evidence-based infection prevention practices in VA medical centers.
METHODS:
This was a sequential mixed methods study involving the collection and analysis of both quantitative and qualitative data. In phase 1 we conducted a written survey of 119 VA Medical Centers and 678 non-VA hospitals from across the nation. In phase 2, we conducted 38 semi-structured phone interviews with participants at fourteen purposefully selected hospitals, two to four at each hospital, between July 19, 2005 and May 12, 2006. For the third and final phase of the study we augmented the phone interview data by conducting 48 interviews in person during site visits at six hospitals between October 26, 2006 and September 27, 2007. Institutional review board approval was obtained from the VA Ann Arbor Healthcare System as well as the local IRB for each of the hospitals that we visited. Analyses of quantitative data were conducted using primarily multivariable techniques, such as logistic regression. All interviews were transcribed, extensive summary reports generated for each site and practice, and analyses were conducted by the multidisciplinary study team to identify salient key themes.
FINDINGS/RESULTS:
The overall response rate for the written survey was 74% (80% of VA Medical Centers and 72% of non-VA facilities responded). The sample used for our quantitative analyses, however, consisted of only VA Medical Centers (n = 95) and hospitals that were part of a national stratified random sample of non-federal general medical/surgical hospitals (n = 421), thus excluding hospitals that were surveyed as part of an oversample of Michigan hospitals. Results from the analysis of quantitative and qualitative data collected during the course of the study, focusing specifically on the prevention of device-related infections, include the following:
To prevent Central-Venous Cather Related Blood-Stream Infections (CVC-BSI), a higher percentage of VA hospitals reported using maximal sterile barrier precautions (84% vs. 71%, p = .01) and chlorhexidine gluconate for insertion site antisepsis (91% vs. 69%, p < .001), both recommended practices, compared to their non-VA counterparts. There were no significant differences between VA and non-VA facilities in the use of antimicrobial central venous catheters, avoidance of routine central line changes or use of an antimicrobial dressing with chlorhexidine (a practice for which there is no guideline recommendation). However, use of a composite approach was significantly higher for VA hospitals compared to non-VA hospitals (62% vs. 44%, p = .003). Even after adjustment, there was a statistically significant positive association between VA and two practices of interest. Specifically, the odds of using chlorhexidine gluconate were nearly five times greater and the odds of using a composite approach two times greater for VA hospitals compared to non-VA hospitals.
To prevent catheter-related urinary tract infection (UTI), overall, 30% of hospitals regularly used antimicrobial urinary catheters and portable bladder scanners; 14% regularly used condom catheters in men; and 9% regularly used catheter reminders. VA hospitals were more likely than non-VA hospitals to use bladder scanners (49% vs. 29%, p < .001), condom catheters (46% vs. 12%, p < .001), and suprapubic catheters (22% vs. 9%, p<.001); non-VA hospitals were more likely to use antimicrobial catheters (30% vs. 14%, p = .002). We have also identified five recurrent themes that characterize how U.S. hospitals have addressed hospital-acquired UTI: 1) while hospital-acquired urinary catheter-related infection was a low priority for many hospitals, timely removal of urinary catheters was considered important; 2) identifying a committed "champion" - who was not necessarily a physician -- and the use of financial incentives to employees facilitated prevention activities in several sites; 3) relatively small non-rigorous hospital-specific pilot studies were important in deciding whether or not to use novel devices such as anti-infective catheters; 4) economic considerations influenced hospital-acquired UTI prevention activities; and 5) external forces, such as directives and public reporting influenced UTI surveillance and prevention activities.
To prevent ventilator associated pneumonia (VAP) we found that overall, 83% of hospitals reported regularly using semi-recumbent positioning; only 21% used subglottic secretion drainage. There were no significant differences between VA and non-VA hospitals in the use of these practices. While participating in a collaborative initiative (such as IHI) was significantly associated with use of semi-recumbent positioning, multivariable analyses provided little guidance regarding use of subglottic secretion drainage. Our qualitative findings, however, revealed three themes that help explain why hospitals were using - or not using - these two practices. First, collaboratives, which often employ practice bundles, have had a strong influence on the use of semi-recumbent positioning but little effect on subglottic secretion drainage. Second, nurses have played a major role in the use of semi-recumbent positioning but are not strongly engaged in the use of subglottic secretion drainage. Finally, there is considerable debate about the evidence to support subglottic secretion drainage, despite a supportive meta-analysis of 5 randomized trials, but little discussion about the evidence supporting semi-recumbent positioning (two randomized trials, one negative).
In addition to these specific findings, our analysis also revealed several common themes related to leadership, mission or culture, personnel and resources that influence practice adoption and implementation and how these factors may interact with different types of implementation strategies (e.g., use of champions, participation in a collaborative).
IMPACT:
The results of this study show that VA hospitals are doing as well and in many cases better than non-VA hospitals in using recommended practices to prevent device-related infections. However, there remains room for improvement particularly in the prevention of urinary tract infections. This research has also identified a number of factors that can impede or facilitate practice adoption and implementation but perhaps even more importantly suggests that a hospitals unique organizational or environmental context may make certain implementation strategies more or less effective at promoting practice use. As such, better understanding this context can help to identify those strategies that may be best suited to facilitate adoption and implementation of proven infection prevention practices at that facility with the ultimate aim of decreasing infection risk and improving patient safety.
PUBLICATIONS:
Journal Articles
- Saint S, Kowalski CP, Forman J, Damschroder L, Hofer TP, Kaufman SR, Creswell JW, Krein SL. A multicenter qualitative study on preventing hospital-acquired urinary tract infection in US hospitals. Infection Control and Hospital Epidemiology. 2008; 29(4): 333-41.
- Krein SL, Hofer TP, Kowalski CP, Olmsted RN, Kauffman CA, Forman JH, Banaszak-Holl J, Saint S. Use of central venous catheter-related bloodstream infection prevention practices by US hospitals. Mayo Clinic Proceedings. 2007; 82(6): 672-8.
- Olmsted RN, Kowalski CP, Krein SL, Saint S. Reading habits of infection control coordinators in the United States: peer-reviewed or non-peer-reviewed evidence? American Journal of Infection Control. 2006; 34(10): 616-20.
- Krein SL, Olmsted RN, Hofer TP, Kowalski C, Forman J, Banaszak-Holl J, Saint S. Translating infection prevention evidence into practice using quantitative and qualitative research. American Journal of Infection Control. 2006; 34(8): 507-12.
