Health Services Research & Development

Veterans Crisis Line Badge
Go to the ORD website
Go to the QUERI website

SAF 04-031 – HSR&D Study

New | Current | Completed | DRA | DRE | Portfolios/Projects | Centers | Career Development Projects

SAF 04-031
Translating Infection Prevention Evidence to Enhance Patient Safety
Sarah L. Krein PhD RN
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: October 2004 - September 2008

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

  1. Miller BL, Krein SL, Fowler KE, Belanger K, Zawol D, Lyons A, Bye C, Rickelmann MA, Smith J, Chenoweth C, Saint S. A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center. Infection control and hospital epidemiology. 2013 Jun 1; 34(6):631-3.
  2. Krein SL, Kowalski CP, Harrod M, Forman J, Saint S. Barriers to reducing urinary catheter use: a qualitative assessment of a statewide initiative. JAMA internal medicine. 2013 May 27; 173(10):881-6.
  3. Saint S, Greene MT, Kowalski CP, Watson SR, Hofer TP, Krein SL. Preventing catheter-associated urinary tract infection in the United States: a national comparative study. JAMA internal medicine. 2013 May 27; 173(10):874-9.
  4. Apisarnthanarak A, Khawcharoenporn T, Greene MT, Kennedy E, Krein S, Saint S. National survey of Thai infection preventions in the era of patient safety. American journal of infection control. 2013 Apr 1; 41(4):362-4.
  5. Krein SL, Kowalski CP, Hofer TP, Saint S. Preventing hospital-acquired infections: a national survey of practices reported by U.S. hospitals in 2005 and 2009. Journal of general internal medicine. 2012 Jul 1; 27(7):773-9.
  6. Buis LR, Kotagal LV, Porcari CE, Rauch SA, Krein SL, Richardson CR. Physical activity in postdeployment Operation Iraqi Freedom/Operation Enduring Freedom veterans using Department of Veterans Affairs services. Journal of rehabilitation research and development. 2012 Apr 5; 48(8):901-11.
  7. Chenoweth CE, Saint S. Urinary tract infections. Infectious Disease Clinics of North America. 2011 Mar 1; 25(1):103-15.
  8. Mody L, Bradley SF, Galecki A, Olmsted RN, Fitzgerald JT, Kauffman CA, Saint S, Krein SL. Conceptual model for reducing infections and antimicrobial resistance in skilled nursing facilities: focusing on residents with indwelling devices. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2011 Mar 1; 52(5):654-61.
  9. Krein SL, Damschroder LJ, Kowalski CP, Forman J, Hofer TP, Saint S. The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study. Social science & medicine (1982). 2010 Nov 1; 71(9):1692-701.
  10. Saint S, Howell JD, Krein SL. Implementation science: how to jump-start infection prevention. Infection control and hospital epidemiology. 2010 Nov 1; 31 Suppl 1:S14-7.
  11. Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. The importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative study. Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America. 2010 Sep 1; 31(9):901-7.
  12. Mody L, Saint S, Galecki A, Chen S, Krein SL. Knowledge of evidence-based urinary catheter care practice recommendations among healthcare workers in nursing homes. Journal of the American Geriatrics Society. 2010 Aug 1; 58(8):1532-7.
  13. Research Committee of the Society of Healthcare Epidemiology of America, Sinaii N. Charting the course for the future of science in healthcare epidemiology: results of a survey of the membership of the Society of Healthcare Epidemiology of America. Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America. 2010 Jul 1; 31(7):669-75.
  14. Easter JS, Josephson SA, Vinton DT, Saint S, Edlow JA. Clinical problem-solving. All in the family. The New England journal of medicine. 2010 Jun 3; 362(22):2114-20.
  15. Damschroder LJ, Banaszak-Holl J, Kowalski CP, Forman J, Saint S, Krein SL. The role of the champion in infection prevention: results from a multisite qualitative study. Quality & Safety in Health Care. 2009 Dec 1; 18(6):434-40.
  16. Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. How active resisters and organizational constipators affect health care-acquired infection prevention efforts. Joint Commission Journal on Quality and Patient Safety. 2009 May 1; 35(5):239-46.
  17. Forman J, Creswell JW, Damschroder L, Kowalski CP, Krein SL. Qualitative research methods: key features and insights gained from use in infection prevention research. American journal of infection control. 2008 Dec 1; 36(10):764-71.
  18. Mody L, Saint S, Kaufman SR, Kowalski C, Krein SL. Adoption of alcohol-based handrub by United States hospitals: a national survey. Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America. 2008 Dec 1; 29(12):1177-80.
  19. Krein SL, Kowalski CP, Damschroder L, Forman J, Kaufman SR, Saint S. Preventing ventilator-associated pneumonia in the United States: a multicenter mixed-methods study. Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America. 2008 Oct 1; 29(10):933-40.
  20. 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 : the official journal of the Society of Hospital Epidemiologists of America. 2008 Apr 1; 29(4):333-41.
  21. Saint S, Kowalski CP, Kaufman SR, Hofer TP, Kauffman CA, Olmsted RN, Forman J, Banaszak-Holl J, Damschroder L, Krein SL. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2008 Jan 15; 46(2):243-50.
  22. 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. Mayo Clinic. 2007 Jun 1; 82(6):672-8.
  23. 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 Dec 1; 34(10):616-20.
  24. 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 Oct 1; 34(8):507-12.
Center Products

  1. Krein SL. Using Implementation and Mixed Methods Research to Translate Infection Prevention Evidence Into Practice. 2011 May 26.
  2. Krein SL. Implementing Change: The Socio-Adaptive Aspects of Preventing CAUTI. 2011 Jan 13.
  3. Krein SL, Meddings J. Implementing Evidence to Prevent Catheter-Associated Urinary Tract Infection: A State-wide and a Unit-based Approach. 2010 Nov 30.
VA Cyberseminars

  1. Krein SL. Implementing Evidence to Prevent Catheter-Associated Urinary Tract Infection. [Cyberseminar]. 2011 May 19.
  2. Krein SL. The Use of Mixed-Methods to Study Translating Infection Prevention Evidence into Practice. [Cyberseminar]. 2010 Oct 6.
Conference Presentations

  1. Krein SL. Putting the Patient Into the Patient Aligned Care Team. Paper presented at: AcademyHealth Annual Research Meeting; 2012 Jun 24; Orlando, FL.
  2. Krein SL. Introduction to Qualitative and Mixed Methods. Paper presented at: Society for Healthcare Epidemiology of America Spring Conference; 2012 Apr 14; Jacksonville, FL.
  3. Krein SL. Appropriate Urinary Catheter Placement in the Emergency Department. Paper presented at: Michigan Health and Hospital Association ER Workshop; 2011 Sep 28; Grand Rapids, MI.
  4. Saint SK. Art & Science of Leadership and followership in Preventing Infection. Paper presented at: Health Research and Educational Trust Catheter-Associated Urinary Tract Infection Meeting; 2011 Jun 7; Columbia, MO.
  5. Saint SK. Implementing Change: The Technical and Social-Adaptive Aspects of Preventing CAUTI. Paper presented at: Health Research and Educational Trust Catheter-Associated Urinary Tract Infection Meeting; 2011 Jun 7; Columbia, MO.
  6. Saint SK. Preventing Catheter-Relating Infections: The Evidence, the Guidelines, and Your Daily Practice. Paper presented at: Society of Hospital Medicine Annual Meeting; 2011 May 10; Grapevine, TX.
  7. Saint SK. Implementing Change: The Art & Science of Leadership and Followership in Preventing Healthcare-Associated Infection. Paper presented at: Association for Professionals in Infection Control and Epidemiology Wisconsin Conference; 2011 Apr 28; Pewaukee, WI.
  8. Krein SL. Integrating Qualitative and Mixed Methods into Your Infection Prevention Initiatives. Paper presented at: Society for Healthcare Epidemiology of America Scientific Annual Meeting; 2011 Apr 2; Dallas, TX.
  9. Saint SK. The Art and Science of Implementation: The Role of Leadership and Followership in Preventing Infection. Paper presented at: Society for Healthcare Epidemiology of America Scientific Annual Meeting; 2011 Apr 1; Dallas, TX.
  10. Saint SK. The Art & Science of Clinical Problem-Solving. Paper presented at: Baylor College of Medicine Grand Rounds; 2011 Mar 10; Houston, TX.
  11. Saint SK. Enhancing Patient Safety by Translating Infection Prevention Research into Practice. Paper presented at: Baylor College of Medicine Infectious Diseases Journal Club; 2011 Mar 9; Houston, TX.
  12. Saint SK. The Art and Science of Leadership and Followership. Paper presented at: Society of Hospital Medicine Annual Meeting; 2011 Feb 23; Breckenridge, CO.
  13. Saint SK. Clinical Problem-Solving. Paper presented at: Society of Hospital Medicine Annual Meeting; 2011 Feb 23; Breckenridge, CO.
  14. Krein SL, Kowalski CP, Hofer TP, Saint S. What VA and Non-VA Hospitals are Doing to Prevent Hospital-Acquired Infections: 2005-2009. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; Washington, DC.
  15. Krein SL, Kowalski CP, Hofer TP, Saint SK. Preventing Hospital-Acquired Infection in U.S. Hospitals: 2005-2009. Presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 29; Minneapolis, MN.
  16. Krein SL, Kowalski CP, Saint SK. Preventing Catheter-Associated Urinary Tract Infection in U.S. Hospitals: 2005-2009. Poster session presented at: Society of Hospital Medicine Annual Meeting; 2010 Apr 10; Washington, DC.
  17. Krein SL. What U.S. Hospitals Are Doing to Prevent Hospital-Acquired Infection 2005-2009. Paper presented at: International Conference on Healthcare-Associated Infections; 2010 Mar 20; Atlanta, GA.
  18. Krein SL. Implementing Evidence to Prevent Catheter-Associated Urinary Tract Infection and Enhance Patient Safety. Paper presented at: University of Michigan School of Nursing Dean's Lecture and Research Day Conference; 2009 Oct 15; Ann Arbor, MI.
  19. Krein SL. Turning Evidence into Practice. Paper presented at: Michigan Society for Infection Prevention and Control Education Fall Conference; 2009 Oct 15; Lansing, MI.
  20. Krein SL. Translating Infection Prevention Research into Practice. Paper presented at: Evidence-Based Practice Center National Conference; 2009 Apr 2; Baltimore, MD.
  21. Saint, Kowalski, Krein SL. What Practices Are U.S. Hospitals Using to Prevent Hospital-Acquired Urinary Tract Infection and Why? A Mixed-Methods Study. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 12; Pittsburgh, PA.
  22. Krein SL, Kowalski, Kaufman, Forman, Damschroder, Saint. Preventing Ventilator-Associated Pneumonia in U.S. Hospitals: A Mixed Methods Study. Paper presented at: Society for Healthcare Epidemiology of America Scientific Annual Meeting; 2008 Apr 7; Orlando, FL.
  23. Olmsted, Krein SL, Kowalski CP, Kauffman CA, Saint. Infection Control Programs Across the U.S.: Program Characteristics and Barriers to Translating Research into Practice. Poster session presented at: Association for Professionals in Infection Control and Epidemiology Annual Conference; 2007 Jun 28; San Jose, CA.
  24. Saint SS, Hofer TF, Kowalski CP, Olmsted RN, Kauffman CA, Forman, Banaszak-Holl J, Krein S. The Use of Central Venous Catheter-Associated Bloodstream Infection Prevention Practices by U.S. Hospitals: A National Mixed Methods Study. Poster session presented at: Society of Hospital Medicine Annual Meeting; 2007 May 23; Dallas, TX.
  25. Saint SS, Hofer TP, Kowalski CP, Olmsted RN, Kauffman CA, Forman JF, Damschroder LD, Kaufman SK, Banaszak-Holl, J JBH, Krein SL. How are US Hospitals Preventing Infections Due to Central Venous and Urinary Catheter? Paper presented at: Society of General Internal Medicine Annual Meeting; 2007 Apr 28; Toronto, Canada.
  26. Saint, S, Hofer, T, Kowalski, CP, Olmsted, RN, Kauffman, CA, Forman, J, Damschroder, L, Kaufman, S, Banaszak-Holl, J, Krein, S. The Use of Nosocomial Urinary Tract Infection (UTI) Prevention Practices By U.S. Hospitals: A National Mixed-Methods Study. Paper presented at: Society for Healthcare Epidemiology of America Scientific Annual Meeting; 2007 Apr 1; Baltimore, MD.
  27. Krein SL, Hofer T, Kowalski C, Holl-Banaszak J, Sanjay S. Adoption of Device-Related Infection Prevention Practices by U.S. Hospitals. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 26; Seattle, WA.
  28. Olmsted RN, Kowalski CP, Krein SL, Saint S. Survey of Reading Habits of Infection Control Coordinators in the United States: Peer-Reviewed or 'Throwaway' Evidence? Paper presented at: Association for Professionals in Infection Control and Epidemiology Annual Conference; 2006 Jun 14; Tampa, FL.
  29. Krein SL, Hofer T, Kowalski C, Saint S. Adoption of Infection Prevention Practices by VA and non-VA Hospitals. Paper presented at: VA HSR&D National Meeting; 2006 Feb 16; Arlington, VA.


DRA: Health Systems
DRE: none
Keywords: Safety, Translation
MeSH Terms: none