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Health care-associated infections (HAIs) cause significant illness in the United States, with an estimated 1.7 million cases and 99,000 deaths in 2002.1 Traditionally, clinicians
have assumed that some HAIs are inevitable. In recent years, two important factors have driven a change in attitude from "HAIs are inevitable" to "HAI prevention
the increasing incidence of these infections; and
the accumulation of data showing that certain HAIs could be prevented.
The concept of inevitability of HAIs has become less convincing.
And, as health care organizations became more involved in the outcome measurement
of care, including public reporting of HAIs, it has become more difficult to accept
that any specific HAI rate, even if low, is satisfactory.
Thus, there has been a new focus on prevention
of HAIs, with influential entities like the Government Accountability Office and the Institute of Medicine weighing in on the issue.2, 3 Evaluation of the literature is the first step in defining specific activities
that could be taken to prevent HAIs with the goal of implementation on a broad scale. Interestingly, data are available for several specific areas, such as perioperative antibiotics and positioning for the prevention
of ventilator-associated pneumonia. Many other areas in need of HAI prevention
are not well studied. It is notable, however, that implementation clearly lags behind even the convincing data provided
in the literature. The general inertia of medical
care to change has prevented forward motion despite good intentions. The articles in this edition of FORUM highlight areas where change has been made in a variety of settings based on best evidence available.
Inevitably, as program implementation moves forward, research gaps are identified.
For instance, are we certain that active surveillance is necessary in a MRSA program?
That we know the optimum degree of bed elevation necessary for prevention of ventilator-associated pneumonia? Or that we know the value of each individual hand hygiene episode as indicated in current guidance? Is there good evidence to support methodology for implementation of these programs at the local and national levels? Gaps such as these at both the scientific and implementation stages are critical for future interventions that will have measurable, positive outcomes.
The challenges for the research arena are many and varied. For the basic science component, interest and funding are always issues. While traditional mechanisms are available for the molecular epidemiology components of antibiotic resistance and infection prevention, funding for the large studies necessary with regard to implementation
may be more difficult. Since most HAIs are low-incidence events, most studies need to be large enough to have sufficient power to show a difference based on standard
study protocols. Such studies do not generally have a natural home in granting
agencies. Also, since the studies would involve large numbers of patients, often at many hospitals, the problem of consent becomes critical. For instance, if a VA study divided the country into two regions — calling
for active MRSA surveillance in one region
and no active surveillance in the other (a control group) — would each patient making
up the nearly 600,000 annual admissions to VA facilities need to sign an individual consent form?
Another challenge is defined in attempts to translate research data into implementation strategies. For instance, is it better to initiate change through direct orders, appeal to the intellectual and analytical strengths of the caregivers, or just deal with top management concerning the hazards of not preventing HAIs? Is there a need for input from human factors researchers, anthropologists, and psychologists in addition to the traditional health care groups in order to effect change? How do we deal with conflicting or incomplete
data since clear best practice evidence may not exist for all things that may need to be tested or implemented? Can modeling be used to complement fuzzy data?
There are many challenges to improving the care of patients with particular emphasis on prevention of HAIs. We should, however, be optimistic that advances are being made through numerous efforts such as those highlighted in this newsletter -- patient care is improving, and many individual patients are not suffering morbidity and mortality related to HAIs. With the emphasis in the Secretary's transition initiatives on Veteran-centric care that incorporates preventing health care-associated complications, this is the perfect opportunity for VA to stay in the forefront of the scientific knowledge base underlying guidance and implementation
for prevention of health care-associated infections.
Klevens RM et al. "Estimating Health Care-Associated
Infections and Deaths in U.S. Hospitals, 2002." Public Health Reports 2007; 122:160-6.
- U.S. Government Accountability Office. Health Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections. April 16, 2008. GAO-08-673T.
- Institute of Medicine. "Report Brief: Initial National Priorities for Comparative Effectiveness Research." June 2009.