Healthcare–associated infections (HAIs) are a significant cause of illness and death in all healthcare settings. They affect 1 out of every 20 hospital patients at any given time. The Agency for Healthcare Research and Quality (AHRQ) recognizes this tremendous public health problem. As a lead Federal agency charged with improving healthcare, AHRQ has patient safety responsibilities spanning 3 broad areas1: (1) identify the risks and hazards that cause or have the potential to cause healthcare–associated injury or harm; (2) design, implement, and evaluate tools resources and patient safety practices that eliminate known hazards, reduce the risk of injury to patients, and create a positive safety culture; and (3) provide technical assistance to institutions to facilitate the adoption-effective safe practices for the elimination or mitigation of healthcare–associated infections throughout the US healthcare community.
The period between 2000 and 2007 was pivotal to setting the stage for AHRQ’s future HAI portfolio. The timeline of critical milestones and related policies begins in 2000 with the Institute of Medicine’s publication of To Err is Human. This study put a spotlight on the issue of patient safety in America’s healthcare system.2
AHRQ’s Patient Safety Portfolio was established in 2001 and seeks to prevent, mitigate, and decrease medical errors and risks to patients. The Portfolio accomplishes its goals by funding health services research in a number of key areas, including HAIs.3
In October 2003, the Michigan Hospital Association launched a 2-year AHRQ grant-funded initiative, MHA Keystone: ICU, to reduce HAIs in patients in intensive care units.4 In 2006, Pronovost and colleagues reported the successful results in the New England Journal of Medicine showing up to a 66% reduction in catheter-related bloodstream infection rates over the 18-month study period.5,6
Shortly thereafter, AHRQ established the Patient Safety Organization Privacy Protection Center (PSOPPC) to support implementation of the Patient Safety and Quality Improvement Act of 2005.7 The PSOPPC offers technical assistance to healthcare providers to develop and implement patient-safety improvement strategies, as well as assistance in submitting information on patient safety events to the Network of Patient Safety Databases.8
During FY 2007–2010, AHRQ funded a number of contracts and grants focused on expanding the HAI research base and implementing prevention strategies.
To address the national epidemic of HAIs, in 2009, the Department of Health and Human Services (HHS) developed the HHS Action Plan to Prevent Healthcare-associated Infections,9,10 which focused on HAI prevention in acute care hospitals. AHRQ was one of 4 agencies leading the development of the Action Plan, along with CMS, the Centers for Disease Control and Prevention (CDC), and the Office of the Assistant Secretary of Health. AHRQ’s focus was on: prioritizing measures and 5-year national targets for HAI reduction and prevention; aligning and standardizing data definitions across agencies; and working with state and regional groups on program and project implementation. This leveraged previous HAI efforts by the Agency. The second version of the Action Plan, which included a broadened scope into other health settings, called the National Action Plan to Prevent Healthcare-associated Infections: Roadmap to Elimination (National Action Plan), was released in April 2012.11 AHRQ’s role was largely focused on research in terms of both supporting and conducting research on ways to prevent and reduce HAIs and on how to produce quality healthcare. In addition, AHRQ expanded the Comprehensive Unit-based Safety Program (CUSP) initiative nationwide, managed the Network of Patient Safety Databases, and oversaw the evaluation of the Action Plan.11
This paper provides insight to AHRQ’s Patient Safety Portfolio and, specifically, HAI prevention strategies by: first, discussing the structure of AHRQ’s HAI research portfolio; secondly, describing the process of HAI prevention practice implementation and lessons learned; and third, explaining outcomes and impacts of the AHRQ program. Researchers, policymakers, and healthcare professionals will gain a better understanding of the AHRQ HAI prevention research portfolio and national impact in relation to the National Action Plan.
STRUCTURE OF AHRQ’s HAI RESEARCH PORTFOLIO
AHRQ’s Patient Safety Portfolio aims to prevent, mitigate, and decrease the number of medical errors, patient safety risks, and quality gaps associated with healthcare.1,3 AHRQ has invested in projects and programs to prevent HAIs, both internally and through its extramural funding vehicles. The HAI emphasis evolved through a growing national and congressional focus, as described in the introduction and background section of this paper. Funding has grown markedly, from <$500,000 in 2003 to $34 million in 2010. During FY 2007–2010, AHRQ funded 33 contracts and 18 grants12 that focused on expanding the HAI knowledge base and implementing HAI prevention strategies, influenced by the National Action Plan.10 AHRQ also began to focus efforts on specific HAIs during this period. In 2008, in response to a $5 million appropriation, AHRQ established an Inter-Agency MRSA Initiative work group, whose charge was to identify projects that would create new knowledge and tools for clinicians and healthcare organizations to prevent, diagnose, treat, and demonstrate prevention of, and reductions in, MRSA infections in all pertinent settings.13,14 Projects from 2007–2010 have addressed the problem of HAIs in diverse healthcare settings, including hospitals, ambulatory settings, and long-term care facilities.15 AHRQ expects these efforts to yield meaningful findings and tools that should be brought to scale as part of the ongoing effort to mitigate and prevent HAIs.
A number of key factors framed the structure of AHRQ’s HAI research portfolio. These include: resource and time constraints, the Agency’s funding criteria, and key stakeholder input (Table 1).
Resource and Time Constraints
Generally speaking, from 2007 to 2010, AHRQ was allocated a large amount of HAI-related research funds that needed to be awarded to research projects in a relatively short time. To award funds within the given time frame, AHRQ had to rely heavily on existing contract mechanisms, including the Accelerating Change and Transformation in Organizations and Networks (ACTION) mechanism, which is limited to previously formed groups of research partners.16 There was initially an especially high need for clinical and epidemiological research for several HAI conditions, which AHRQ was not best-positioned to manage, given its limited expertise in infection control. Since 2007, AHRQ has been able to increasingly use additional grant opportunities and other mechanisms, expand the contractor and grantee base of its HAI work, and add staff with specific infection control expertise.
Key HAI funding criteria include:
AHRQ’s mission, to improve the quality, safety, efficiency, and effectiveness of healthcare, emphasizes implementation research and translating research into practice.17 Thus, the agency’s HAI portfolio has been centered on patient safety practices that mitigate adverse events and reduce harm through applied research. AHRQ plays a significant role in providing technical assistance in spreading evidence-based prevention practices and interventions.
Although AHRQ promotes an applied objective, agency staff observed that the funding criteria took into account the state of knowledge on a topic and the research gaps that a project might fill on the continuum of translating research into practice.
This research continuum includes both research and implementation. Three categories on the research continuum are: (1) upstream research on basic infection science, (2) development and piloting of solutions, and (3) research about how to implement those solutions. Next on the continuum are direct implementation, roll-out, and scale-up of interventions, different, but complementary to research on how to implement or offer technical assistance. This is similar to NIH’s model of translational research.18
Using this framework, AHRQ first looked for circumstances containing enough information and evidence in the upstream categories to support implementation activities. If information was lacking in categories 1 or 2 along the research continuum, then the Agency would need to wait for that evidence to accrue or to invest in upstream research, even if it is somewhat outside AHRQ’s typical funding scope.
Critical Emerging Areas
AHRQ’s focus has evolved to now considering critical HAI problems that pose emerging patient safety threats. This criterion is meant to ensure that the agency’s funded projects remain a step ahead of arising problems. For example, the agency has funded select projects related to Clostridium difficile and carbapenem-resistant Enterobacteriaceae as well as efforts addressing HAIs in nonhospital settings. Its goals in funding such projects are to anticipate national priorities and to build the foundation for future focal areas of the National Action Plan.19
In addition to national priorities, resource and time constraints, and various funding criteria, AHRQ also utilized key stakeholder input to shape its portfolio of HAI prevention research. Specifically, AHRQ sought input from: the National Action Plan, other key federal agencies, AHRQ leadership, AHRQ staff, and private stakeholders.20
AHRQ’s HAI research portfolio was in part shaped by whether or not a proposed project addressed one of the 6 focal HAIs prioritized in the National Action Plan: central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), surgical site infections, ventilator-associated pneumonia, methicillin-resistant Staphylococcus aureus (MRSA), and C. difficle. Similar priority has been given to the healthcare settings of the National Action Plan, including acute care hospitals, ambulatory surgery centers and ESRD facilities, and long-term care.
AHRQ has relied on the input of other federal agencies (particularly CDC and CMS) regarding the funding decision process. CDC has provided epidemiological and infection control expertise to discussions and rankings of proposed projects. If CDC could not pursue projects for budgetary reasons and considered the topic to be critical, they would occasionally suggest to AHRQ some more epidemiologically oriented, upstream projects. When such topics met AHRQ’s funding criteria, AHRQ was open to considering the projects. The projects yielded a productive collaboration and useful scientific results.
CMS was an early partner in AHRQ’s deliberations and formation of HAI-related projects. AHRQ staff has utilized CMS’ expertise on perspectives on payment issues regarding incentive problems and aligning interventions with regulatory payment requirements, as well as by providing subject matter expertise to projects addressing more general HAI measurement and improvement topics.
AHRQ organized interagency group meetings to solicit advice from other agencies. This process proved to be extremely helpful in nurturing ongoing relationships across agencies.
AHRQ leadership (ie, senior leadership team) was extremely helpful throughout planning of HAI priorities for the Agency, as well as with project selection and funding procedures. AHRQ staff was also utilized in shaping the HAI research portfolio. In addition, as required, AHRQ solicited advice and input from private stakeholders, such as key infection control experts, including professional societies.12
Despite the limited time frame for allocating awards, individuals from outside the Agency have commended AHRQ for successfully awarding the funds rationally, efficiently, and credibly, in part due to the National Action Plan and national coordination of efforts.12
IMPLEMENTATION PROCESS AND LESSONS LEARNED
AHRQ identified important implementation issues and lessons learned from HAI projects in its portfolio. In addition, the agency has recognized a number of key areas for future research pertaining to gaps in current HAI knowledge.
Key implementation science issues include21:
Initiative Overload and Fatigue Among Healthcare Organizations and Providers
AHRQ recognizes that this can represent major obstacles to further expansion and implementation of HAI prevention interventions. AHRQ is seeking to identify strategies for more unified approaches to HAI measurement, requirements, and practices to mitigate this problem.21
Infrastructure Development and Coordination
Related to initiative overload, this topic addresses the broader issue of coordinating existing infrastructure and programs for promoting HAI prevention across levels of the healthcare system.19,20 AHRQ realizes the importance of this topic both for implementation of practices at the health system level but also in terms of national coordination amongst federal agencies in implementing programs and priorities.
Understanding Differences in Organizational and Unit Culture
This topic is related to the issue of motivation for the behavioral changes described above for antibiotic prescribing. Often, providers and other stakeholders are aware of and understand evidence-based guidelines, but are unable to effectively change behavior and support new practice patterns.
Business Case for HAI Prevention Interventions
Analyses of the relative costs and benefits of HAI prevention efforts are important in the current resource-constrained healthcare environment and should be undertaken in uniform ways. This may require methodological research and political sensitivity because, although HAI interventions do not necessarily have to save money to be worthwhile, it is important to know the investment required for various prevention strategies and accompanying tradeoffs.
NATIONAL IMPACT AND OUTCOMES OF AHRQ’S HAI RESEARCH
AHRQ’s investments into HAI prevention research and implementation have yielded significant impacts, most notably in reducing CLABSI in intensive care units.4,5 On the basis of the success of the Michigan Keystone project,4 AHRQ has funded projects to implement the CUSP to address CLABSI, and now CAUTI, nationwide. Reduce MRSA is another successful project in terms of both scientific findings and creating useful information for adoption and dissemination.22 AHRQ also reports 5 projects with notable results and 7 promising projects worth discussion. The CUSP, Reduce MRSA, and other notable and promising projects are discussed in detail below and shown in Table 2.
CUSP for CLABSI, and its more recent variants for other HAI conditions, is described as AHRQ’s signature HAI contribution.5 The project is a foundational study promoting acceptance of the preventability of HAIs and one that led to the increased visibility and size of AHRQ’s HAI research portfolio. CUSP for CLABSI achieved a successful national roll-out and significant results, reducing CLABSI rates by 40% from baseline.38 This has led to its adaptation to several other HAI conditions, including CAUTI, ventilator-associated pneumonia, surgical site infections, and ESRD.
The CUSP intervention is comprised of a combination of effective behavioral change strategies and bundles of HAI-specific prevention practices, often a checklist with traditional infection control techniques. The adaptation process is critical, ensuring proper time is taken to adapt both the behavioral change strategies and specific prevention practices for the new setting or HAI. Other agencies have noted generally good coordination of CUSP with other CLABSI initiatives, despite CLABSI’s being a crowded space, which may result in lessons for future programs regarding implementation. Similarly, AHRQ emphasizes the potential lessons to be learned from the CUSP projects for national roll-out and scale-up of interventions, as well as how to adapt proven change strategies to other HAIs and healthcare settings.
Reduce MRSA, a translational research project jointly funded by AHRQ and CDC, also yielded significant results.22 It was a trial designed to assess comparative effectiveness of different strategies to reduce or prevent MRSA (universal vs. targeted decolonization or screening and isolation). It also yielded, specific, actionable information useful for disseminating to practitioners to change clinical practice and improve outcomes. Another major lesson from this project is the utility of horizontal interventions addressing the spectrum of infections, compared with vertical interventions targeting a single HAI (which are also critical in their own right), when underlying implementation processes and clinical practices are similar.
Five projects are identified as yielding notable contributions to HAI research and practice to date (methodology described elsewhere12). Seven projects have expected promise of producing significant contributions. In some instances, these 7 projects have not yet produced significant contributions because of the projects’ early stage, problems in execution that precluded demonstration of the likely full intervention effects, or the intervention point (eg, identifying risk factors for an HAI that provides important foundation for downstream research but does yield a payoff immediately). The 5 projects with notable results and 7 promising projects are shown in Table 2.
This paper discusses HAI prevention research within the Patient Safety Portfolio at AHRQ. We discuss the history of HAI prevention research at AHRQ with critical milestones contributing to its development. In addition, we focus on the decisions to fund HAI projects and provide context for the HAI Portfolio at AHRQ. We share implementation-related lessons learned and future areas of research for the Agency. This paper also describes major research results and contributions that have emerged from AHRQ-funded HAI projects.
We describe the national impact that has emerged from AHRQ’s funded HAI research. AHRQ was given a large amount of funding to disburse in a short period of time and that the agency successfully initiated a well-conceived array of HAI research projects. AHRQ has since expanded its base of contractors and grantees to which it awards HAI-related work and has augmented Agency staff to include in-house infection-control experts. The Agency has used a balanced set of funding criteria that adhere to AHRQ’s mission to focus on healthcare improvement and quality, while being closely aligned with research priorities of the National Action Plan and sufficiently flexible to support projects along the research continuum that move the HAI prevention field toward those goals. The projects examined, many of which focus on implementation of HAI prevention practices, yield useful lessons learned for future implementation of efforts and research endeavors and show significant impact of AHRQ’s program in reducing HAIs.
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