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 is imperative:” (1) the increasing 

incidence of these infections; and (2) 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. 

A New Focus on HAI Prevention

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.

Challenges for Research Arena

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 

FORUM

Translating research into quality health care for Veterans

Commentary

Research and Prevention of Health CareAssociated Infections

Gary A. Roselle, M.D., VHA National Director, Infectious Diseases Program, VA 

Central Office and Chief, Medical Service, Cincinnati VA Medical Center

 May 2010

Contents

Director’s Letter 2

Response to Commentary 3

Research Highlight

• Reducing MRSA Health 

Care-Associated Infections 4

Research Highlight

• Tackling Hand-Hygiene 

Compliance: An Organizational 

Approach 5

Research Highlight

• Preventing Catheter-Associated 

Urinary Tract Infection 6 

Research Highlight

• Creating Systems to Improve 

ICU Outcomes 7

A publication of the VA Office of Research & Development, 

Health Services Research & Development Service, Center 

for Information Dissemination and Education Resources, in 

conjunction with AcademyHealth. 

 “This sickness doth infect 

the very lifeblood of our 

enterprise.”

— William Shakespeare 

Source: King Henry IV, Part 1

VA FORUM 4-2010.indd 1 4/28/10 1
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 Veterancentric 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.

References

1 Klevens RM et al. “Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002.” 

Public Health Reports 2007; 122:160-6.

2 U.S. Government Accountability Office. Health CareAssociated Infections in Hospitals: Leadership Needed from 

HHS to Prioritize Prevention Practices and Improve Data on 

These Infections. April 16, 2008. GAO-08-673T.

3 Institute of Medicine. “Report Brief: Initial National 

Priorities for Comparative Effectiveness Research.” 

June 2009.

Director’s Letter

HSR&D is uniquely positioned to facilitate the implementation 

of evidence-based research into policy and clinical practice. This 

is the core of HSR&D’s mission. Engagement of stakeholders 

(i.e., field and VA Central Office (VACO), operations and managers, patient care staff, and Veterans), as appropriate, early in the 

research process is key to the success of this mission.

Input from stakeholders can be invaluable, initially when conceiving a research project, 

and subsequently to facilitate its eventual implementation and systematization. A first 

step is to determine, given the nature and scope of the project, who at a particular medical center, Veterans Integrated Service Network (VISN), or in VACO may be interested 

in providing input. As an example, in the article by Jain and Evans in the current issue 

of FORUM, a research project related to MRSA infections must acknowledge VHA’s 

current MRSA Prevention Program, and possibly incorporate developing programmatic 

policies and procedures into the project’s research goals. For other articles in this issue, 

the project that involved hand washing (Lukas and Petzel) and the project addressing 

prevention of catheter-associated urinary tract infections (Render, Hasselbeck, and Almenoff) would likely involve different sets of stakeholders. 

As the research project progresses, to maintain engagement, researchers should 

periodically update VHA stakeholders. Finally, as the project nears completion, 

researchers should consider next steps. For example, how likely is a successful 

research intervention to be sustained following the research project’s conclusion? 

What additional research may be required? Are the project’s research results sufficiently significant to warrant a subsequent broad implementation project? Who is 

responsible for the next steps? Even if the particular research team will not pursue 

a related project, a responsibility remains to support follow-up efforts. Because 

VHA is an integrated health care system, peer reviewed publications are required 

but not sufficient. 

There are many stages of a research endeavor. Each stage can benefit from stakeholder counsel and expertise. While it may take considerable effort to identify the 

most relevant stakeholders and maintain contact, benefits can be immeasurable. 

The VA research community provides a wealth of collaborative opportunities, which I 

strongly urge all researchers to consider when planning their research projects. 

Seth A. Eisen, M.D., M.Sc.

Director, HSR&D

VA Office of Research & Development, Health Services Research & Development Service May 2010

VA FORUM 4-2010.indd 2 4/28/10 1
VA Office of Research & Development, Health Services Research & Development Service May 2010

I appreciate Dr. Roselle highlighting the pervasiveness of HAIs, thus demonstrating their critical 

importance and the need for both implementation 

and further research. I share his conviction that 

HAIs have finally gained the national attention of 

the public, policymakers, Congress, and funding 

agencies. This is a promising time when funding is 

finally being targeted to address questions of comparative effectiveness, including the broader definition favored by VA and AHRQ, which includes 

issues related to delivery systems, implementation, 

and reengineering. 

As Dr. Roselle points out, HAIs are not unavoidable. HAIs are due to the practices and behaviors 

of everyone in health care settings. A complex 

adaptive systems framework suggests the concept 

of emergence. We find that success at one level 

precipitates new challenges at the next level. As 

effective programs develop and become systematized, just as in ecocycles, there is a creative destruction or reorganization phase. 1 

Hospitals that have tackled HAIs as an organizational change challenge – rather than continuing 

to delegate HAIs to the infection control program 

– are those that have seen dramatic reductions in 

MRSA and other HAIs and dramatic improvements in quality in other domains.2

 Partnering with 

facility and VISN leadership, and engaging teams of 

committed health care staff volunteers in owning, 

driving, and measuring change is effective, creative, 

and sustainable.

If anything, now is the time for even greater efforts 

to bring together operations leaders, clinicians, staff 

and researchers for more regular conversation, 

perhaps at regional and national meetings, in order 

for operations to help focus us on the important 

clinical and management issues that need further 

research because they are not easily solvable. VA 

should find opportunities to bring operations and 

researchers together, to apply their conceptual 

frameworks, develop new quick methods and 

evaluation methodology, and solve key problems 

for Veterans.

Dr. Roselle points out correctly that many of the 

specific questions regarding details of policy and 

how to implement them are not studied and remain 

open questions. However, the lack of evidence 

for many interventions should not delay action in 

improving health care processes and quality. Model 

health care systems like VA and Intermountain 

Healthcare have shown the value of focusing on 

identifying high prevalence conditions, describing 

variation in processes and eliminating that variation through quality improvement and information solutions. Effective managers do not wait for 

evidence. There is too much work to be done in 

transforming our health care systems and much of 

it needs to be done now.

I remain impressed that my colleagues in HSR&D 

have been tackling these difficult problems for a 

number of years, as the articles here show. In fact, 

one of the challenges in conducting such research 

in implementation science and system redesign 

is that our funding and publishing mechanisms 

remain too slow to fund thoughtful evaluations 

of important natural experiments and changes in 

systems that happen quickly. I agree that there is a 

keen need for further research in implementation 

science, effective organizational change strategies, 

and how to effectively integrate information and 

communication technology into workflow and 

practice. Some of the many recent VA innovations 

in operations – with formation of the VA Systems 

Redesign Office and Steering Committee, and 

forming and funding the VA Engineering Resource 

Centers – are important steps. 

Dr. Roselle also highlights that the engagement o

other specialties is needed to truly make a difference. The Pittsburgh VAMC showed the value o

bringing expertise in engineering and social scien

to bear in driving organizational change to redes

their processes and engage staff hospital wide. I 

fully agree and have found that bringing informaticists, engineers, cognitive scientists, commu

nications specialists, sociologists, and many othe

disciplines together to tackle important impleme

tation science problems is not only fulfilling, but 

brings cutting edge methods to bear and creative 

solutions to previously “unsolvable” problems.

Further, there is a call for immediate new strateg

directions in rethinking how computational tech

nology can best support cognitive processes and 

decisions in a fundamentally different informatio

system that will make effective, patient-centered 

care possible.3 The VA Consortium for Healthca

Informatics Research (CHIR) and Veterans’ Info

matics, Information and Computing Infrastructu

(VINCI) are two important, multicenter VA init

tives designed to make electronic health informa

tion readily available for quality improvement 

and research, and fostering collaboration in new 

ground-breaking approaches not possible outsid

VA. Our VA informatics colleagues are actively 

planning the next generation of a new informatio

system for VA.

These new directions for research, operations, 

care coordination, Office of Health Informatio

(OHI), and all of VA are truly crucial innovatio

that bring together clinicians, managers, staff, r

searchers, and trainees to tackle tough problem

together. I hope that VA leadership, Office of 

Research and Development (ORD), and all of 

seek crucial opportunities for conversations to

gether, find common ground, and work togeth

collaboratively to design the new VA.

References

1 Frances Westley, Brenda Zimmerman, and Michael Quinn 

Patton. Getting to Maybe: How the World has Changed. Random 

House Canada, 2006.

2 Katherine Ellingson, Nancy Iversen, Jerry M. Zuckerman, 

for the Positive Deviance MRSA Prevention Partnership.

“A Successful Multi-Center Intervention to Prevent Transm

sion of Methicillin-resistant Staphylococcus aureus (MRSA

The Society for Healthcare Epidemiology of America (SHE

19th Annual Scientific Meeting, March 21, 2009.

3 William W. Stead, Herbert S. Lin (eds), Committee on Eng

ing the Computer Science Research Community in Health 

Care Informatics. Computational Technology for Effective Health 

Care: Immediate Steps and Strategic Directions. Washington, D.C

National Academies Press, 2009.

Response to Commentary

Crucial Opportunities for Addressing HAIs

Bradley N. Doebbeling, M.D., M.Sc., Senior Investigator, VA HSR&D Center on 

Implementing Evidence-Based Practice, Indianapolis, Indiana

“Strength is derived from 

unity. The range of our 

collective vision is far greater 

when individual insights 

become one.”

 — Andrew Carnegie

VA FORUM 4-2010.indd 3 4/28/10 1
A 2005 survey conducted by the Centers 

for Disease Control and Prevention (CDC) 

found that more than 94,000 patients in 

the United States developed serious infections from Methicillin-resistant Staphylococcus 

aureus (MRSA) resulting in an estimated 

18,650 deaths. This figure was more than 

the deaths from HIV/AIDS that year. 

Nationwide, MRSA is the most common 

cause of ventilator-associated pneumonias 

and surgical site infections, the fourth most 

common cause of central line-associated 

bloodstream infections, and the eighth 

most common cause of catheter-associated 

urinary tract infections. MRSA infections 

have been a growing problem in private and 

VA medical facilities. Because there are few 

antibiotics that are effective against MRSA, 

effective infection prevention and control 

strategies to prevent the spread of MRSA 

within health care systems are essential.1

Toyota Production System 

Principles 

In 2002, the VA Pittsburgh Healthcare System (VAPHS) began collaboration with the 

Pittsburgh Regional Healthcare Initiative 

and the CDC to adopt the principles of the 

Toyota Production System (TPS) to reduce 

transmission of MRSA and MRSA health careassociated infections (HAIs). The approach 

was piloted on a surgical ward at VAPHS. 

The key strategies implemented included: (1) 

surveillance cultures for MRSA on all admissions and discharges; (2) prompt isolation (in 

contact precautions) of patients found to be 

colonized or infected with MRSA; and (3) an 

aggressive hand hygiene training program. 

Using TPS, MRSA infections on the surgical 

ward decreased 60 percent over four years. The 

strategy was expanded to the Surgical Intensive 

Care Unit (ICU), where a 75 percent reduction 

in MRSA HAIs was realized over three years.2

In 2005, the program was expanded to include 

all acute care units at VAPHS and reductions 

of similar magnitude were noted on all acute 

care units.

The VAPHS experience with TPS showed 

that health care systems and processes could 

change with positive outcomes. The model 

was successful in decreasing MRSA HAI rates; 

however, application of TPS was resource 

intensive. In order to expand the program in 

a cost effective manner, VAPHS explored a 

process called Positive Deviance (PD), described at www.positivedeviance.org. With 

PD, “culture change” where infection control 

becomes everyone’s responsibility, was added 

to the original three strategies to decrease 

MRSA infections. Active surveillance, contact 

precautions, hand hygiene, and culture change 

became known as the “VA MRSA Bundle.” 

Recognizing the success of VAPHS in controlling MRSA HAIs and seeking to validate the 

process, VA Central Office provided VAPHS 

with funding to support trials of the MRSA 

Bundle at other VAs. Thirty-nine VA facilities 

applied to be b-test sites, and 17 were selected. 

Six elected to undergo formal PD training. All 

b-sites agreed to collect MRSA process and 

compliance data and report through the CDC’s 

National Healthcare Safety Network (NHSN) 

beginning in October 2006.

The VHA MRSA Program Office, in collaboration with researchers at the Center 

for Health Equity Research and Promotion 

(CHERP) based at VAPHS, conducted a 

qualitative evaluation using in-depth interviews to describe the key strategies and 

potential pitfalls involved with implementation of the Directive. A majority of the 

participants believed that using a cultural 

transformation approach was necessary for 

the program to succeed because it allowed 

staff to buy-in and get involved.3

VHA-Wide Implementation

The original plan for VHA-wide implementation was projected to occur in a staged 

process over two to three years. However, 

the Secretary of Veterans Affairs visited 

VAPHS in December 2006, and saw firsthand the success the institution was having 

in controlling MRSA. Recognizing the importance of MRSA prevention in Veterans’ 

lives, the Secretary released Directive 2007-

002 in January 2007, authorizing implementation of the MRSA Prevention Initiative 

and all components of the “MRSA Bundle” 

in one ICU or other high-risk area in all 

VHA acute care facilities by March 2007. It 

directed all acute care units to implement 

the Initiative by December 31, 2007. 

Implementation of the MRSA Prevention 

Initiative in Community Living Centers 

began in December 2008, with guidelines 

developed specifically for the homelike setting. Guidelines have also been developed 

for spinal cord injury units, polytrauma units, 

inpatient mental health units, and ambulatory 

care/outpatient settings. By the end of April 

2010, the MRSA Prevention Initiative will 

have been deployed VHA-wide.

Data from the VHA MRSA Prevention Initiative from inception of the program to the present are currently being analyzed. Preliminary 

results suggest significant changes in MRSA 

HAI rates in the ICU and non-ICU setting as 

well as significant decreases in MRSA transmission among patients during their hospital stay. 

References

1. Baracco GJ, Muder RR, Jain R. Methicillin-resistant 

Staphylococcus aureus: What’s the Big Deal? Federal Practitioner 2009; December:41-7.

2. Muder RR, Cunningham C, McCray E, et al. Implementation of an Industrial Systems-Engineering Approach to Reduce the Incidence of Methicillin-resistant 

Staphylococcus aureus Infection. Infection Control and Hospital 

Epidemiology 2008; 29:702-8.

3. Garcia-Williams AG, Miller LJ, Burkitt KH, et al. Beyond beta: Lessons Learned from Implementation of 

the Department of Veterans Affairs MRSA Prevention 

Initiative. Infection Control and Hospital Epidemiology 2010, 

in press.

VA Office of Research & Development, Health Services Research & Development Service May 2010

Research Highlight

Reducing MRSA Health CareAssociated Infections

Rajiv Jain, M.D., Director, VHA MRSA Prevention Program,

and Acting Chief Consultant for Medical-Surgical Services in the Office 

of Patient Care Services, and Martin E. Evans, M.D., Associate Director, 

VHA MRSA Prevention Program

VA FORUM 4-2010.indd 4 4/28/10 1
VA Office of Research & Development, Health Services Research & Development Service May 2010

Hand hygiene is one of the simplest yet most 

effective processes for reducing infections in 

patient care. Hand-hygiene compliance has been 

the subject of directives in VA and a visible priority in recent surveys of The Joint Commission, 

national standards by the CDC, and an extensive 

campaign by the World Health Organization. 

But despite this high priority and strong evidence 

that has been available for years, compliance is at 

best variable. This seemingly simple practice has 

proven very difficult to bring to reliably high levels of compliance across an organization. 

In an effort to improve hand-hygiene compliance, 

the Center for Organization, Leadership and 

Management Research (COLMR) worked closely 

with VISN 23 on a recently completed, three-year 

intervention based on the premise that although 

hand hygiene is an individual act, achieving high 

rates of compliance requires interdependent organizational action. 

Organizational Components to 

Facilitate Improvement

Consistent with our hypotheses, we found that 

hand-hygiene compliance was strengthened by 

the presence of three interacting organizational 

components that medical center managers and 

clinicians can affect: (1) robust clinical process redesign to engage staff and incorporate evidencebased practices in routine operations; (2) active 

top leadership commitment to the redesign effort; 

and (3) links to management structures and processes to support, align, and integrate redesign. 

Among the seven participating medical centers in 

VISN 23, four facilities showed high presence of, 

or fidelity to, these components (fidelity scores of 

3.17 to 3.95 on a 4-point scale) while three facilities had lower scores (1.42 to 2.15) showing only 

partial presence. The four high-fidelity facilities 

demonstrated statistically significant hand-hygiene 

improvement over the course of the project while 

the lower-fidelity facilities did not. The highfidelity facilities also had consistently higher handhygiene scores at the end of the project. These 

fidelity scores reflect real differences between the 

high- and lower-fidelity groups in their patterns 

of behavior and activities across the three model 

components. 

Clinical process redesign. All facilities in 

the study used a variety of education and 

awareness strategies to improve hand-hygiene 

compliance. However, the high-fidelity facilities 

went beyond education and awareness to also 

undertake process engineering and culture 

change. Clinical redesign was characterized 

by energetic, multidisciplinary improvement 

teams. Teams had strong leaders with excellent project management skills who often 

paired with clinical leaders and often included 

experienced improvement experts. All teams 

went beyond basic process redesign methods 

to explore higher reliability interventions as 

compliance plateaued. In the lower-fidelity group, 

clinical process redesign was often more ad 

hoc. Teams, if appointed, never got off the 

ground or fell away due to time constraints. 

Teams collected data but did not use them 

to help understand possible sources of noncompliance or the impact of their intervention 

activities. Often, lower-fidelity facilities felt 

their teams lacked the leadership, authority, or 

infrastructure to accomplish their goals. 

Active top leadership commitment. In the 

high-fidelity group, senior facility leaders were 

supportive of and involved in hand-hygiene 

improvement efforts. Perhaps most important, 

senior leadership involvement and support was 

consistent over time. Senior leaders set clear 

expectations about target levels of compliance 

and sent the message that current practices were 

deficient. In the lower-fidelity group, senior leaders 

either did not see hand hygiene as a high priority 

or expressed support but were not consistent in 

their involvement. In some cases, they modeled 

good hand hygiene and, for example, addressed it 

if it came up on patient safety and environmentof-care rounds, but they generated little sense of 

urgency for improvement. 

Links to senior management structures and 

processes. In the high-fidelity group, there were 

explicit strategies to link improvement efforts 

to senior management. All facilities identified a 

member of the leadership team as a champion 

to work actively with the hand-hygiene redesign 

team. There were clear lines of accountability for 

performance that did not meet its targets. Facility 

managers provided resources, such as staff time, 

for the hand-hygiene improvement efforts. Attention to hand hygiene was regularly rewarded 

and hand-hygiene success celebrated. In the lowerfidelity group, senior leadership champions were 

less consistently identified and involved. Handhygiene data tended to be reviewed by standing 

performance improvement or patient safety committees buried several layers below leadership. 

The result of such disconnection was that project 

teams felt they did not get consistent direction, 

cross-department issues went unresolved, and 

hard-won successes were not recognized. 

Implications

Although the three components associated with 

significant hand-hygiene improvement are within 

managers’ control, implementing them is not 

always easy. In this project, the presence of the 

three components varied despite an intervention that was consistent across facilities. Facilities 

with the highest fidelity to the three components 

– and through those components to improved 

hand-hygiene performance – were those that (1) 

shared the urgency to improve compliance with 

hand hygiene and (2) had a positive improvement 

climate including staff experience with quality improvement and organizational values for 

improvement. These factors suggest dimensions 

that a medical center might assess to determine 

the features on which it needs to build in order to 

implement the three components successfully. 

While improved hand-hygiene compliance was 

the short-term project objective, the broader aim 

was to test whether focused organizational support of improvement initiatives and alignment of 

the initiatives with broader organizational goals 

strengthens the ability of VA medical centers to 

implement evidence-based clinical practices. 

Research Highlight

Tackling Hand-Hygiene Compliance: 

An Organizational Approach

Carol VanDeusen Lukas, Ed.D., Center for Organization, Leadership and Management Research, VA Boston Healthcare System, Boston, Massachusetts, 

and Robert A. Petzel, M.D., VA Under Secretary for Health

VA FORUM 4-2010.indd 5 4/28/10 1
Urinary catheters are frequently used in hospitalized patients and result in substantial morbidity 

and costs due to catheter-associated urinary tract 

infection (CAUTI). Urinary catheters may also 

cause non-infectious complications resulting 

from reduced mobility or urethral trauma from 

improper placement or removal. Despite the 

clinical and economic consequences of CAUTI, 

a 2005 national survey of both VHA and nonVHA hospitals revealed that preventing CAUTI 

was a low priority for most U.S. hospitals, with 

little attention given to either CAUTI or urinary 

catheters as a patient safety problem.1

Several recent initiatives may lead to increased 

attention on preventing CAUTI, including: 

(1) changes in the Centers for Medicare and 

Medicaid Services (CMS) reimbursement policy 

to not pay hospitals for the costs incurred for 

hospital-acquired CAUTI; (2) publication of 

CAUTI prevention recommendations by the 

Centers for Disease Control and Prevention 

(CDC)/Healthcare Infection Control Practices 

Advisory Committee (HICPAC) and others 

(www.cdc.gov/hicpac/cauti/001_cauti.html); 

and (3) a statewide collaborative in Michigan 

that focuses specifically on the prevention of 

CAUTI,2 using an approach that successfully 

reduced rates of central line-associated bloodstream infection (CLABSI).3 

Have these initiatives been effective? While 

complete results are not yet available, preliminary 

data collected in 2009 through another national 

survey suggest there is still much to be done to 

prevent CAUTI in U.S. hospitals. For example, 

the CMS payment change does not affect VHA 

hospitals and so has not increased CAUTI as a 

hospital priority within VHA. However, even for 

non-VHA hospitals, of which the majority report 

that payment changes have led to a moderate 

to large increase in the prevention of CAUTI 

as a hospital priority, the reported use of most 

prevention practices remains low. Specifically, 

both timely removal of urinary catheters and 

using them only when indicated are perhaps the 

most effective methods for preventing CAUTI 

or other catheter-associated complications. Yet, 

many hospitals – both VHA and non-VHA – do 

not have a routine system for monitoring catheter 

placement or discontinuation, and the implementation of effective strategies to promote appropriate use remains elusive. Even in Michigan, where 

most hospitals have been involved in a program 

that focuses on the timely removal of urinary 

catheters, efforts to reduce inappropriate catheter 

use have been variable.

What can be done? Besides identifying potential gaps in the prevention of health careassociated infection, and specifically CAUTI, 

the focus of our research is to develop, test, 

and evaluate strategies to address these gaps. 

Currently we are working with the Michigan 

Hospital Association Keystone Center for 

Patient Safety and Quality and hospitals in 

Michigan to assess and, building on current 

efforts, to develop effective CAUTI prevention strategies across hospitals.2

 In addition, 

we look forward to collaborating with the 

VA’s Inpatient Evaluation Center (IPEC) 

and others as part of a VHA focused CAUTI 

prevention initiative. While our approach to 

CAUTI prevention will likely include many of 

the same general strategies used in prior infection prevention efforts (e.g., the model used by 

Pronovost and colleagues to reduce CLABSI),3

preventing CAUTI presents several unique 

challenges: (1) the lack of highly effective products or approaches for preventing CAUTI; (2) 

the ubiquity of urinary catheter use throughout 

the hospital and not primarily in a specialized setting like the intensive care unit; and, 

(3) the limited importance placed on CAUTI 

prevention by hospital personnel. Challenges 

notwithstanding, some of the fundamental 

components for preventing CAUTI include:

VA Office of Research & Development, Health Services Research & Development Service May 2010

Research Highlight

Preventing Catheter-Associated 

Urinary Tract Infection in U.S. 

Hospitals: From Ideas to Action

Sarah L. Krein, Ph.D., R.N., and Sanjay Saint, M.D., M.P.H., HSR&D Center 

for Clinical Management Research, Ann Arbor, Michigan 

Goldstein Receives 2010 Under Secretary’s Award for 

Outstanding Achievement

Mary K. Goldstein, M.D., M.S., has received this year’s prestigious 

Under Secretary’s Award for Outstanding Achievement in Health Services Research. The award recognizes a VA researcher whose work has 

met three key criteria: improved our understanding of factors that affect

the health of Veterans and improved the quality of their care, contributed to the future of VA health services research by inspiring and training the next generation of investigators, and enhanced the visibility of 

VA research through national recognition within the research community. 

For more than 18 years as a VA health services researcher, Dr. Goldstein has brought scientific 

distinction to the VA Palo Alto Healthcare System through her contributions to health services 

research, and has clearly exemplified the three major criteria for this award. Dr. Goldstein 

serves as Director of the Geriatrics Research Education and Clinical Center (GRECC) at the VA 

Palo Alto Health Care System. 

Dr. Goldstein’s research focuses on functional status in geriatrics, hypertension management, application of clinical guidelines and guidelines compliance, and automated clinical 

decision support systems. Her work in health informatics is known nationally and internationally. Throughout her career, Dr. Goldstein has shared her expertise and experience by 

actively mentoring VA researchers and clinicians. Over the years, she has generated more 

than 100 publications, including journal articles and book chapters, in the areas of hypertension, geriatrics, decision-making, and decision support. 

Robert A. Petzel, M.D., Under Secretary for Health, presented the award to Dr. Goldstein at 

the VA Research Week Forum in Washington, D.C. in April.

continued on page 8

VA FORUM 4-2010.indd 6 4/28/10 1
VA Office of Research & Development, Health Services Research & Development Service May 2010

Infections acquired as a consequence of hospitalization are costly and common. In a 2001 

review, which ranked safety practices based 

on the evidence and potential for impact and 

effectiveness, practices to reduce hospitalacquired infections ranked highly.1

 The Saving 

100,000 Lives campaign of the Institute for 

Healthcare Improvement and the elimination 

of payment for infectious complications of 

hospitalization by Medicare and other insurers 

represent external efforts that have targeted 

hospital-acquired infections.2

The VA Inpatient Evaluation Center (IPEC) 

provides infrastructure to improve outcomes 

in hospitalized Veterans. IPEC uses information technology to measure variation in outcomes and evidence-based practices, provides 

benchmarked feedback to both senior and 

middle-level managers, and creates learning 

tools for implementation. Organizationally, VA 

leadership plays a central role in establishing 

IPEC targets for improvement through an executive board composed of senior regional, national, and local leaders, and a clinical advisory 

board composed of an ICU director and nurse 

manager from each of the 21 VA regions. 

Reducing Central Line-Associated 

Bloodstream Infection and Ventilator Pneumonia in the ICU

In the fall of 2005, VA Operations asked IPEC 

to support the implementation of evidencebased practices (EBP) in the intensive care unit 

(ICU) to reduce central line-associated bloodstream infections (handwashing, sterile gown 

and gloves, bed-sized drape, cap and mask, 

avoidance of the femoral site, early removal) 

and ventilator-associated pneumonia (elevation 

of head of the bed, coordinated daily sedation 

vacation and spontaneous weaning trial, daily 

weaning assessment, venous thromboembolism prevention, and stress ulcer prophylaxis). 

The agreement by regional leadership to support these projects as part of VA’s commitment to Saving 100,000 Lives, and inclusion of 

reduction in infection rates in leadership’s performance contract created a strong mandate. 

To create momentum for this initiative, three 

hospitals in the field presented their experience 

in implementing the central line-associated 

bloodstream infections (CLAB) and ventilatorassociated pneumonia (VAP) bundle and reducing infections during a kick-off web-based 

call. IPEC contacted every nurse manager 

and infection control practitioner in VA to 

learn existing use of measures and practices 

to reduce hospital-acquired infections. To 

make implementation easy, a website provided 

tools such as (1) learning modules that offered 

CEUs, (2) examples of forcing functions (line 

cart, checklist for line insertion, and daily goal 

sheet), (3) adaptable policies and procedures, 

(4) an annotated bibliography, and (5) guidance 

for moving practice change. Lacking a system 

to track hospital-acquired infections nationally, we developed a data management website 

where hospitals manually entered infection 

rates using CDC definitions and adherence to 

evidence-based practices. Rates benchmarked 

internally and externally were reported quarterly to multiple levels of leadership. IPEC 

program managers mentored struggling sites 

(infections > 75th percentile) who volunteered.

Results

This implementation experience created a 

template for future initiatives. Facilitators for 

successful implementation included availability 

of pilot sites, feedback benchmarked to similar ICUs, leadership commitment, accessible 

tools to adapt to local circumstances, learning 

strategies that keep new staff up to date on 

expected practices and shared expertise across 

VA hospitals, and a help desk (via the program 

managers at IPEC) to troubleshoot barriers 

and mentor. Barriers included use of older 

frameworks for change (conference room 

planning rather than rapid tests of change), 

time constraints, and tapping interest of a 

physician champion. Given a goal likely to 

improve patient outcomes based on strong evidence, 260/273 ICUs dropped their infection 

rates without coaching or participation in a collaborative process. External drivers from regulators and quality organizations and internal 

drivers such as comparative rates of infections 

in VA and prioritizing the initiative through inclusion in the leadership performance contract 

facilitated the interest of VA leadership. 

Adherence to both the CLAB bundle and 

VAP bundle increased. Adherence to composite EBP for CLAB increased from 85 percent 

in the second quarter of 2006 to 97 percent in 

2009. Adherence to composite EBP for VAP 

increased from 51.6 percent in the second 

quarter of 2006 to 90.6 percent in 2009, and 

ventilator days fell by 8,800 from 2007 to 2009

CLAB rates fell (3.8 to 1.8 /1000 line days; 

p <0.01) overall as did the rate of ventilator 

pneumonia (6.8 to 2.8/ 1000 vent days; p < 

0.01). Struggling sites lacked a functional team, 

forcing functions, and system to provide feedback to frontline staff. 

References 

1. Shojania KG et al. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: 

AHRQ Publication No. 01-E058; 2001.

2. Berwick DM et al. The 100,000 Lives Campaign: Setting a Goal and Deadline for Improving Healthcare 

Quality. Journal of the American Medical Association. 

2006;295(3):324-7.

Research Highlight

Creating Systems to Improve ICU Out- comes: Reducing Central LineAssociated Bloodstream Infections 

and Ventilator Pneumonia in VA ICUs

Marta L. Render, M.D., Chief, VA Inpatient Evaluation Center, Cincinnati, 

Ohio, Rachael Hasselbeck, M.S.N., Director, Implementation, VA Inpatient 

Evaluation Center, Cincinnati, Ohio, and Peter Almenoff, M.D., Assistant 

Deputy Under Secretary for Quality and Safety, VA Office of Quality and Safety, 

Kansas City, Missouri 

VA FORUM 4-2010.indd 7 4/28/10 1
David Atkins, M.D., M.P.H.,

QUERI Director,

VA Central Office, 

Washington DC

Peter L. Almenoff, M.D., 

FCCP, Assistant Deputy 

Under Secretary for Health 

for Quality and Safety, VA 

Central Office, Washington DC

Cynthia Caroselli, Ph.D., R.N.,

Associate Director for Patient 

Services & Chief Nurse 

Executive, VA New York 

Harbor Health Care System, 

New York, NY

Martin P. Charns, D.B.A., 

Director, VA HSR&D Center 

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc

Director, HSR&D

VA Central Office, 

Washington DC

Joseph Francis, M.D., M.P.H

Chief Quality and 

Performance Officer, VA Cen

tral Office, Washington DC 

Rodney A. Hayward, M.D., C

Director, VA HSR&D 

Center of Excellence, 

Ann Arbor, MI

Alan S. Perry, M.H.A., 

FACHE, Director, VA 

Central California Health 

Care System, Fresno, CA

Frances Weaver, Ph.D.,

Director, VA HSR&D Cen

of Excellence, Hines, IL

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

1) A simple summary of key recommendations 

for preventing CAUTI such as through the 

mnemonic “ABCDE” (see box). 

2) Engaging nurses as key champions for 

CAUTI prevention and appropriate urinary 

catheter use.

3) Education about catheter risks with particular emphasis on non-infectious as well as 

infectious complications.

4) Use of stop-orders or nurse-based removal 

protocols, either computerized or paperbased.

5) Establishing consistent, rigorously derived 

(yet practical and user-friendly) indications 

for catheter placement and discontinuation.

Improving patient safety and quality of care 

requires moving beyond simply disseminating 

scientific evidence. Nevertheless, identifying 

and implementing effective strategies to ensure the use of proven practices in real-world 

clinical settings remains challenging. Our 

in-depth study of hospital-based infection 

prevention – with a focus on CAUTI – is an 

example of research underway throughout VA 

to address this challenge. While we hope to 

reduce CAUTI and improve urinary catheter 

use in hospitals across the United States, our 

broader goal is to use infection prevention as 

a model for developing methods for uncovering and then addressing the many complexities 

that affect the safety of hospitalized patients. 

References

1 Saint S, et al. A Multicenter Qualitative Study on Preventing 

pital Acquired Urinary Tract Infection in U.S. Hospitals. Infe

Control and Hospital Epidemiology 2008; 29:333-41.

2 Saint S, et al. Translating Hospital-Associated Urinary Tract 

fection Prevention Research into Practice via the Bladder Bu

Joint Commission Journal on Quality and Patient Safety 2009; 25:44

3 Pronovost PJ, et al. Improving Patient Safety in Intensive Ca

Units in Michigan. Journal of Critical Care 2008; 23:207-21.

Catheter-Associated Urinary Tract Prevention 

continued from page 6 Catheter-Associated Urinary 

Tract Prevention: 

Recommendations2

• Adherence to general infection control principles (e.g., hand hygiene, surveillance and 

feedback, aseptic insertion, proper maintenance, education) is important.

• Bladder ultrasound may avoid indwelling 

catheterization.

• Condom catheters or other alternatives 

to an indwelling catheter such as intermittent catheterization should be considered 

in appropriate patients. 

• Do not use the indwelling catheter unless 

you must!

• Early removal of the catheter using a 

reminder or nurse-initiated removal 

protocol appears warranted.

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