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Infection prevention moves across care continuum
Research in surgery centers, hemodialysis, LTC
As patients have moved, infections have moved with them. Accordingly, there is a surge of interest and research funding to implement and improve infection prevention beyond the hospital. The Agency for Healthcare Research and Quality (AHRQ) has made non-hospital settings a key focus in its recent $34 million initiative to prevent health care associated infections (HAIs).
"AHRQ is really focusing on ambulatory surgical settings, clinics, long-term care areas that have not been as attended to as acute care," says Elaine Larson, PhD, professor of pharmaceutical and therapeutic Research at the Columbia University School of Nursing in New York City. "I think it's terrific. It's recognizing that there needs to be more attention to prevention of infections across settings. "
Consider, for example, the dramatic growth in surgery being performed in ambulatory surgical centers (ASCs). The number of surgery centers in the U.S. has gone from 336 in 1985 to 5,047 in 2007, AHRQ reports. Ensuring safe practices within these settings has become more critical, particularly since federal inspections have identified breaches in standard infection control measures in some 60% of ASCs, the agency found. In addition to surgery centers, AHRQ's new projects also focus on end-stage renal disease and long-term care facilities, where more than 500,000 patients and more than 1.5 million residents, respectively, are particularly vulnerable to infections.
"We are interested in developing and demonstrating linkages between the various settings of care," says James Cleeman, MD, senior medical officer at AHRQ. "That's a very important issue. Infections don't stay confined to one setting. We are trying to figure out if we can encourage people to develop better ways to link the findings in the various settings of care so that you can track patients from one setting to another."
Some of the key AHRQ infection prevention research projects in non-hospital settings include:
Surgical site and Clostridium difficile infections after ambulatory surgery: This project will determine incidence of CDIs and SSIs after certain procedures performed in ASCs. It will identify facility and patient-level factors associated with increased risk of developing CDIs and SSIs, develop and validate risk prediction models using patient-level factors, and determine clinical outcomes and attributable costs of SSIs and CDIs originating in ASCs.
Healthcare cost and utilization project (HCUP) administrative data initiative to support the evaluation of HAIs in ambulatory surgery settings: This project will further develop the HCUP data infrastructure to provide baseline estimates of HAIs in the ambulatory surgery setting. Implementation strategies aimed at decreasing the occurrence of HAIs in ambulatory surgery settings also will be evaluated. Objectives include:
Project CLEAR Changing lives by eradicating antibiotic resistance: This project will conduct a randomized controlled trial of serial decolonization versus standard-of-care patient education among individuals who are carriers of MRSA upon their discharge from the hospital. It will identify predictors of infection or rehospitalization due to MRSA and of successful MRSA decolonization, and estimate medical and nonmedical costs of MRSA infection among individuals who are carriers of MRSA. The potential for cost savings associated with decolonization will be evaluated.
Multidrug-resistant urinary tract infections in ambulatory settings: This project will identify the phenotypic and genotypic characteristics of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-EB) causing community-onset UTIs, elucidate risk factors for community-onset ESBL-EB UTIs, develop and validate a clinical prediction rule for community-onset ESBL-EB UTIs, and identify the clinical impact of community-onset ESBL-EB UTIs. The project has parallel aims for Klebsiella pneumoniae carbapenemase-producing K. pneumoniae.
Improving infection control practices in end-stage renal disease (ESRD) facilities: This project aims to improve adherence to infection control practices in ESRD facilities to reduce preventable vascular access infections. Objectives include:
Detection, education, research, and decolonization without isolation in long-term care: This project will test the effectiveness of a protocol for admission testing and immediate decolonization of positive persons for MRSA colonization in long-term care facilities. It will develop an infection control outreach program to provide expert guidance on infection disease prevention specific to long-term care facilities and create a model of a hospital-long-term care facilities infection control collaboration.
Preventing/Managing Clostridium difficile for nursing home residents: This project will implement the use of a C. diff infection control bundle in the nursing home. It will enhance communication among providers concerning CDI and other HAIs as individuals transition between nursing homes and hospitals, determine the costs and potential savings resulting from implementation of the intervention, and determine the extent to which nursing homes and hospitals serve as a source of C. diff among individuals transferred between care types.