Evidence-based Practice in Infection Control and Prevention

Getting Evidence intoInfection Control Practice

Mary Ann D. Lansang, MD, FPCP, FPSMIDPHICS Convention

May 29, 2015

Outline• What is Evidence-based Practice (EBP)?• Introduction to key concepts in EBP

o 6 A’so PICOTo RAMBO

• Practice scenario on infection control & prevention• The X factor• Evaluation and quality improvement

What is Evidence-Based Practice?• The application of the best available research

results (EVIDENCE) when making decisions abouthealth care (from: Agency for Effective Healthcare Research &Quality, USA)

• Evidence is used alongside clinical expertise andpatient preferences

• Local/population context is also important

• Origins from “Evidence-Based Medicine” (Sackett etal. British Medical Journal, 1996)

Dr David Sackett: father of EBM(1934 – 2015)

What is Evidence-based Practice?

http://www.cebm.net/

What is Evidence Based Practice?

http://www.cebm.net/

Focus of EBP• Focus on outcomes and costs:

o Reduce unnecessary variations in practiceo Close the gap between evidence and practiceo Enable systematic management of information

overload

• Interventions based on evidence havebetter outcomes

EBP improves patient outcomes

EBM/EBP Key Concepts

• ‘PICOT’• Patient/s• Intervention/s• Comparison• Outcome/s• Time

• 6 A’s1. ASK2. ACCESS3. APPRAISE4. AGGREGATE5. APPLY6. AUDIT

• RAMBO• Recruitment• Allocation• Maintenance• Measurements

• Blind, or• Objective

measure-ments &processes©

The 6 A’s -steps of Evidence-Based Practice1. ASK a focused question2. ACCESS - search for epidemiological evidence to help

answer question3. APPRAISE the evidence for its validity, effect size,

precision)4. AGGREGATE the evidence using the triangle,circle,box,x

FRAMEWORK5. APPLY your decision integrating the aggregated evidence

into the trade-off of (i) benefits versus harms;(ii) patientvalues and preferences, (iii) cost –effectiveness and cost-equity,to make an evidence-based decision

6. AUDIT your practice (i.e. check your actual practiceagainst evidence-based practice on a regular basis)].

Key: Formulate an answerable question from apatient’s (or hospital’s) problem (1)

Problem:• 39 y.o. male is admitted to the hospital for intermittent high-

grade fever and chills since 3 weeks prior to admission• Hemiplegic, with complete spinal cord injury at C6 from a

diving injury in May 2011• Has had multiple pressure sores in sacral area, and healed

with unrecalled antibiotics• 2 days prior to admission: developed a tender, swollen,

fluctuant mass at right gluteal area• Wound C/S showed: MRSA sensitive to clindamycin,

levofloxacin, linezolid and vancomycin; resistant to oxacillin

Key: Formulate an answerable question from apatient’s (or hospital’s) problem (2)

Problem (cont’d):•The Hospital Infection Control Unit has instituted contactprecautions and advised daily bathing/wipes with 2%chlorhexidine•The patient’s wife asks you: Are these really necessary? Do Ihave to wear gowns and gloves all the time? And do we reallyhave to wipe him with chlorhexidine, which is expensive? Isn’tsoap and water not enough?•You, as the healthcare worker, secretly agree yourself that allthese procedures are too tedious and labor-intensive, and alsocosts the hospital too much.•YOU LOOK FOR THE EVIDENCE ON THE EFFECTIVENESS OF THESE

INTERVENTIONS – e.g., contact precautions

EBP Step 1: ASK - turn your questioninto 5 parts (PICOT)

1. Participants (patient(s) you want to treat)2. Intervention( or ‘Exposure’ if no intervention )3. Comparison (there is always an alternative! - another

therapy, nothing …4. Outcome (MCID [Minimal Clinically Important Difference] in the Humanly

Important Outcome [Distress, Disability, Dysfunction, Death]

5. Time frame (over which you expect a result)

Participants

Intervention Group Comparison Group

OutcomesTime

P

I C

OT

PICOT:

the 5 parts of every epidemiological study

OUR PICOT QUESTION1. Participants (patient(s) you want to treat)2. Intervention( or ‘Exposure’ if no intervention )3. Comparison (there is always an alternative! - another

therapy, nothing …)4. Outcome ( MCID [Minimal Clinically Important Difference] in the

Humanly Important Outcome [Distress,Disability,Dysfunction,Death] )5. Time frame (over which you expect a result)

Among patients with MRSA infections,are contact precautions more effective than

standard precautions inpreventing health-care associated infectionsover the period of a patient’s hospital stay?

EBP Step 2: ACCESS - search for thebest evidence to answer your question/s

Use the PICOT components to choose search terms

1. Patient(s): MRSA infections2. Intervention: Contact precautions3. Comparison: Standard precautions4. Outcome Prevention of HAI/nosocomial infections5. Time Period of hospital stay

Among patients with MRSA infections,are contact precautions more effective than hand hygiene

in preventing healthcare associated infectionsover the period of a patient’s hospital stay?

Levels of EvidenceLevel 1: Systematic

review ofrandomized trials

Level 2: Randomized trialor observational study w/

dramatic effect

Level 3: Nonrandomized controlledcohort/follow-up study

Level 4: Case series, case-control studies

Level 5: Mechanism-based reasoning; expert opinion

Evidence Hierarchy forEnvironmental Infection Control

- from: McDonald & Arduino, CID Jan 2013

Good Resource for systematic reviews:Special Collections: Cochrane Library

P

I C

OT

• P

• I

• C

• O

• T

• Recruitment

• Allocation

• Maintenance

• Measurements

• Blind or

• Objectivemeasurements &processes

EBP Step 3: Appraise the evidenceusing RAMBO on the PICOT frame

Participants

Intervention Group &Comparison Group

Outcomes

Time

QUESTION: VALIDITY: RAMBO

Measurement of outcomes?

P

IG CG

OT

DESIGN:Selection?

Allocation?

Maintenance of allocation?

+ -

+-

A BC D

Representative?

Allocation?- Randomized?- Comparable

groups?

Maintenance?- Treated equally?- Compliant?

Measurements:- Blind?- Objective?

Participants

Intervention Group &Comparison Group

Outcomes

Time

QUESTION: VALIDITY:

Measurement of outcomes?

P

IG CG

OT

DESIGN:Selection?

Allocation?

Maintenance of allocation?

+ -

+-

A BC D

1. Fair start?

1. Few drop-out’s?

1. Fair finish?

Participants

Intervention Group (IG) &Comparison Group (CG)

Outcome

IG

CG

+ -+- DC

BA

Allocation?

Selection?

Maintenance of allocation?

QUESTION:

Measurement of outcomes?

DESIGN: VALIDITY

1. Fair start?

2. Few drop outs?

3. Fair finish?

Participants

Intervention Group (IG) &Comparison Group (CG)

Outcome

IG

CG

+ -+- DC

BA

Allocation?

Selection?

Maintenance of allocation?

QUESTION:

Measurement of outcomes?

DESIGN: VALIDITY

1. Fair start?

2. Few drop outs?

3. Fair finish?

Participants

Intervention Group (IG) &Comparison Group (CG)

Outcome

IG

CG

+ -+- DC

BA

Allocation?

Selection?

Maintenance of allocation?

QUESTION:

Measurement of outcomes?

DESIGN: VALIDITY

1. Fair start?

2. Few drop outs?

3. Fair finish?

What about readily accessible practiceguidelines?• From local medical/specialist societies locally and

abroad. Examples:• PHICS• Philippine Society for Microbiology & Infectious Diseases (PSMID)• Asia Pacific Soceity of Infection Control (APSIC)• Society for Healthcare Epidemiology in America (SHEA)

• Databases and general resources. Examples:• Agency for Healthcare Research and Quality (USA): National

Guideline Clearinghouse (www.guideline.gov)• National Institute for Health and Care Excellence (UK): Guidances

(www.nice.org.uk/guidance)• U.S. Centers for Disease Control• World Health Organization

Caution:Not all guidelines are evidence-based.

Six domains:1. Scope and purpose2. Stakeholder involvement3. Rigor of development4. Clarity of presentation5. Applicability6. Editorial independence

Example: SHEA guidelines – are they evidence based?

SHEA guideline update 2014:Strategies to prevent transmission and infection

in acute care hospitals

Quick access and appraisal results (1)

• Jain R et al. NEJM 2011; 364:1419+: Veterans Affairsinitiative to prevent MRSAinfections

• Before – after observationalstudy (Oct 2007-June 2010)o I: “MRSA bundle”: universal nasal

surveillance for MRSA, contactprecautions for pts colonized/infectedwith MRSA, hand hygiene, institution-wideeffort (1.9 M admissions; 8.3 M pt-days)

o C: period before Oct 2007

• Significant decrease of 62%from pre-interventioninfection rates (1.62 MRSAinfections per 1,000 pt days)to the MRSA interventionperiod (0.62 infections per1,000 pt days)

• Huskins WC et al. NEJM2011; 364: 1407+: The STAR-ICU Trial

• A cluster-randomizedcontrolled trialo I: surveillance for MRSA and VRE

colonization + contact precautions(5,434 admissions in 10 ICUs)

o C: existing hospital practice, whichcould include contact precautionsfor MRSA-infected pts (3,705admission in 8 ICUs)

• 6 months study period• No significant difference in

mean ICU level of incidenceof col’n or infection withMRSA/VRE per 1000 pt-daysat risk (40.3 vs 35.6 events)

Quick access and appraisal results (2)

• Jain R et al. NEJM 2011; 364:1419+: Veterans Affairsinitiative to prevent MRSAinfections

• All acute care units (exceptpsychiatry

• Inherent limitations of anuncontrolled before-and-after studyo VA system had introduced new

VAP and CLBSI guidelines theprevious year

o Issued a new guidancedocument on MRSAdecolonization 6 months afterstart of intervention

o More awareness andeducation during theintervention period:“institutional cultural change”as part of the MRSA bundle

• Huskins WC et al. NEJM2011; 364: 1407+: The STAR-ICU Trial

• Limited to ICUs• Median compliance to

contact precautions:o Gloves: 82%o Gowns: 77%o Hand hygiene: 69%

• Median compliance tostandard precautions:o Gloves: 72%o Hand hygiene: 62%

Quick access and appraisal results (1)

• Jain R et al. NEJM 2011; 364:1419+: Veterans Affairsinitiative to prevent MRSAinfections

• Before – after observationalstudy (Oct 2007-June 2010)o I: “MRSA bundle”: universal nasal

surveillance for MRSA, contactprecautions for pts colonized/infectedwith MRSA, hand hygiene, institution-wideeffort (1.9 M admissions; 8.3 M pt-days)

o C: period before Oct 2007

• Significant decrease of 62%from pre-interventioninfection rates (1.62 MRSAinfections per 1,000 pt days)to the MRSA interventionperiod (0.62 infections per1,000 pt days)

• Huskins WC et al. NEJM2011; 364: 1407+: The STAR-ICU Trial

• A cluster-randomizedcontrolled trialo I: surveillance for MRSA and VRE

colonization + contact precautions(5,434 admissions in 10 ICUs)

o C: universal gloving untilsurveillance cultures negative (3,705admission in 8 ICUs)

• 6 months study period• No significant difference in

mean ICU level of incidenceof col’n or infection withMRSA/VRE per 1000 pt-daysat risk (40.3 vs 35.6 events)

EBP Step 4: AGGREGATE the relevant information &make an evidence-based decision:’ the X-factor

©

Epidemiologicevidence

Clinical /population

healthconsiderations

Policy issues

Patient / communitypreferences

X-factor: making evidence-based decisions

expertise: ‘putting it all together’ the art ofpractice

Step 5APPLY your decision

USE THE ‘GRADE’ FrameworkIntegrating• the aggregated evidence• the trade-off of benefits versus harms•patient values and preferences•cost –effectiveness and cost- equity,

to make an evidence-based decision

http://www.gradeworkinggroup.org/publications/index.htm

Step 6: AUDIT –evaluate & improve performance

1. Determine ‘best’ practice (EBP Steps 1-4)2. Assess current practice: survey3. Compare with best practice - is there a gap?4. Consider reasons for gap, identify processes toreduce gap & implement5. Re-survey: is there any improvement?

= quality improvement / audit

Recap• Evidence-based Practice (EBP)• Introduction to key concepts in EBP

o 6 A’so PICOTo RAMBO

• Application to an infection control problem: levelsof evidence

• The X factor• Evaluation and quality improvement

Huge acknowledgments to:For some EBP slides:• Professor Peter Tugwell, Center for Global Health,

University of Ontario, Canada• Carl Heneghan, Center for Evidence Based

Medicine, University of Oxford, UK (www.cebm.net)