The Centers for Disease Control and Prevention STRIVE Initiative: Construction of a National Program to Reduce Health Care–Associated Infections at the Local Level
Authors: Kyle J. Popovich, David P. Calfee, Payal K. Patel, Shelby Lassiter, Andrew J. Rolle, Louella Hung, Sanjay Saint, Vineet Chopra
Journal: Annals of Internal Medicine (2019)

Supplement: STRIVE1 October 2019The Centers for Disease Control and Prevention STRIVE Initiative: Construction of a National Program to Reduce Health Care–Associated Infections at the Local LevelFREEKyle J. Popovich, MD, MS, David P. Calfee, MD, Payal K. Patel, MD, MPH, Shelby Lassiter, BSN, RN, CPHQ, Andrew J. Rolle, MPH, Louella Hung, MPH, Sanjay Saint, MD, MPH, and Vineet Chopra, MD, MScKyle J. Popovich, MD, MSRush University Medical Center, Chicago, Illinois (K.J.P.), David P. Calfee, MDWeill Cornell Medicine, New York, New York (D.P.C.), Payal K. Patel, MD, MPHUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., S.S., V.C.), Shelby Lassiter, BSN, RN, CPHQHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.L., A.J.R., L.H.), Andrew J. Rolle, MPHHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.L., A.J.R., L.H.), Louella Hung, MPHHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.L., A.J.R., L.H.), Sanjay Saint, MD, MPHUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., S.S., V.C.), and Vineet Chopra, MD, MScUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., S.S., V.C.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-3529 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Health care–associated infection (HAI) remains an important problem in the United States (1, 2). Central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) are among the most common device-associated infections, whereas Clostridioides difficile and methicillin-resistant Staphylococcus aureus (MRSA) are among the most prevalent pathogens causing HAI. In 2011, there were an estimated 721 800 HAIs in U.S. acute care hospitals, with C difficile, S aureus, Enterococcus species, and gram-negative bacilli being the most common pathogens (3). To address the burden of these infections, evidence-based infection prevention strategies, including "bundles" or combinations of interventions, have been developed and successfully implemented in many hospitals to prevent HAIs (4–8). For example, bundles have been created to decrease CLABSI (4), CAUTI (5, 9), and MRSA bloodstream infection (6, 7). In U.S. intensive care units, there has been a substantial reduction in CLABSIs, thought to be in large part due to implementation of bundles (4, 10).Many U.S. hospitals, unfortunately, continue to experience high rates of HAI (11) because of low compliance with infection prevention practices, poor organizational culture, financial limitations, limited engagement from front-line personnel, and limited leadership support (12). Of note, assistance from external sources, such as local, state, and national groups (including public health departments, quality improvement organizations, hospital associations, and academic medical centers), can help reduce HAI (13, 14). However, the ways and extent to which these entities engage with hospitals to improve HAI rates vary, resulting in heterogeneity of outcomes (12). Comprehensive solutions to this complex dynamic within and across hospitals, states, and the country have not been developed. In particular, strategies to help hospitals that continue to have high rates of HAI are needed.To reduce infections in hospitals with high rates of HAI, the Centers for Disease Control and Prevention (CDC) funded a prospective, interventional, nonrandomized, quality improvement program that spanned multiple hospitals and states. Development, implementation, and execution of the program was performed by the Health Research & Educational Trust (HRET), a not-for-profit research and education affiliate of the American Hospital Association, along with several partners, such as state hospital associations (SHAs), professional societies, and scientific experts from academic medical centers. Collectively, the program was titled CDC STRIVE (States Targeting Reduction in Infections via Engagement). This article provides a summary of how STRIVE constructed the building blocks for a national effort intended to reduce HAIs in participating hospitals.Program Goals and StructureThe STRIVE initiative focused on bringing national health care professional societies, subject-matter experts, and state-level health care organizations together with short-stay and long-term acute care hospitals to improve infection prevention and control practices. The overall objective of the program was to identify, partner with, and collaborate with hospitals struggling to reduce HAI by pairing national subject-matter experts with state, regional, and local organizations to effect sustainable change (Figure 1).Figure 1. Overall flow of the CDC STRIVE program.CDC = Centers for Disease Control and Prevention; STRIVE = States Targeting Reduction in Infections via Engagement. Download figure Download PowerPoint To deliver on this ambitious goal, the STRIVE initiative had 3 specific aims: 1) strengthen infection control practices through dissemination and implementation of CDC's Targeted Assessment for Prevention (TAP) strategy; 2) strengthen relationships among SHAs, state health departments, and other state HAI partners, such as the Centers for Medicare & Medicaid Services Quality Innovation Network–Quality Improvement Organizations, to create a structure to facilitate durable implementation of best infection control practices; and 3) provide technical assistance to facilities to improve implementation of infection control practices in existing and newly constructed health care facilities. Reductions in C difficile infection (CDI), CLABSI, CAUTI, and hospital-onset MRSA bloodstream infection in participating hospitals were chosen as measures to determine initiative success.Program planning for STRIVE began in September 2015. Subject-matter experts from multiple organizations were identified by CDC and HRET and brought together to form a national program team to provide oversight for the program and build educational content. Members of the national program team included representatives from CDC, HRET, Association for Professionals in Infection Control and Epidemiology, American Society for Health Care Engineering, Society of Hospital Medicine, and University of Michigan Health System.Stakeholder Considerations in Designing STRIVE InterventionsThe CDC outlined several objectives to increase alignment and coordination of HAI prevention efforts across stakeholders: First, identify strategies to improve infection control implementation activities on a state- and facility-level; second, identify indicators of capacity (infrastructure, staffing, partnerships, and training), ongoing regional collaboratives, and other contextual factors (such as state-level mandates) that may affect implementation of infection prevention efforts; and third, identify roles of state partners (state health departments, SHAs, Quality Innovation Network–Quality Improvement Organizations) in the coordination, integration, and alignment of infection prevention and control activities.Eligibility and Selection of Participating HospitalsThe CDC STRIVE initiative focused specifically on hospitals with a disproportionately high burden of HAI. To target these facilities, the CDC used National Healthcare Safety Network (NHSN) data from the first 2 quarters of 2015 to identify states with hospitals that had a high burden of CDI and a high burden of at least 1 of the following HAIs: CLABSI, CAUTI, or hospital-onset MRSA bloodstream infection. "High burden" was defined by examining the cumulative attributable difference (15) (using the U.S. Department of Health and Human Services' 2020 HAI goals as the standardized infection ratio target). Hospitals with a cumulative attributable difference above the first tertile (that is, the top one third) were designated as having a high burden of HAIs. Data for all 4 infection types were combined to identify hospitals with CDIs plus at least 1 other HAI with cumulative attributable differences above the first tertile.Three methods were used to identify eligible states. First, CDC identified states with the largest number of hospitals that met inclusion criteria. These states thus became the main focus of STRIVE efforts. Second, to include sites that may also benefit from STRIVE, HRET applied the CDC approach with publicly available Hospital Compare state-specific data to identify additional hospitals with a high burden of HAIs not included in the cumulative attributable difference first tertile. Finally, a few interested states not included in the above were allowed to volunteer to participate in STRIVE. Using these methods, 34 states and the District of Columbia were identified for possible inclusion in STRIVE.Rather than approach hospitals directly (and in keeping with the STRIVE goal to strengthen state and local partnerships to combat HAI), HRET shared the list of potentially eligible hospitals with SHAs and asked them to recruit sites. In this way, the CDC and HRET engaged SHAs to reach out to hospitals to inform them about the program, solicit their interest, and recruit them to participate. As word of the intervention and program spread, a few states that were not identified by the CDC also requested to participate in the STRIVE program, because they viewed this program as important to help improve hospital infection control practices.To better consolidate efforts and understand the impact of interventions, recruitment within STRIVE occurred within waves, leading to 4 cohorts of hospitals (Table): cohort 1 (June 2016 to April 2017), cohort 2 (November 2016 to October 2017), cohort 3 (April 2017 to March 2018), and cohort 4 (June 2017 to May 2018). Cohort 1 was identified as a pilot cohort in which interventions to reduce HAI were developed and pilot-tested in conjunction with key stakeholders. In total, 443 short-stay and long-term acute care hospitals from 28 states and the District of Columbia participated in 4 overlapping, 10- to 12-month cohorts (Appendix Figure). In 2015 (before the intervention), the median cumulative attributable difference values for cohorts 2, 3, and 4 were as follows: CAUTI, 0.67 (interquartile range [IQR], –0.62 to 4.22); CLABSI, 1.46 (IQR, –0.02 to 5.44); CDI, 5.04 (IQR, 0.16 to 17.48); and MRSA, 0.45 (IQR, –0.15 to 2.67).Table. Characteristics of Hospitals Participating in the STRIVE ProgramAppendix Figure. States that enrolled with the STRIVE program.In total, 443 hospitals from 28 states and the District of Columbia participated. Recruitment occurred as follows: cohort 1 (June 2016 to April 2017), cohort 2 (November 2016 to October 2017), cohort 3 (April 2017 to March 2018), and cohort 4 (June 2017 to May 2018). Hashing indicates states that participated in more than 1 cohort. STRIVE = States Targeting Reduction in Infections via Engagement. Download figure Download PowerPoint Informing Change—Designing InterventionsPractice Change AssessmentDuring STRIVE, participating hospitals were asked to complete a survey instrument to identify and address gaps in HAI prevention at the beginning of cohort enrollment (baseline) and at the end of the study wave (comparison) (Figure 2). This gap assessment could be done using either the CDC's Infection Control Assessment and Response (ICAR) survey (16) or the STRIVE Practice Change Assessment (PCA). The ICAR had been previously developed for state health departments to assess infection prevention practices in hospitals. The PCA, based on the ICAR, was modified to focus on 8 domains germane to the STRIVE program. Four of the domains focused on specific HAIs—CDI, CLABSI, CAUTI, and hospital-onset MRSA bloodstream infection—whereas the remaining 4 domains focused on hand hygiene, personal protective equipment, environmental cleaning, and antimicrobial stewardship.Figure 2. Education and engagement interventions implemented for participating hospitals.CDC = Centers for Disease Control and Prevention. Download figure Download PowerPoint Baseline surveys were administered by each participating hospital with support and (at times) a site visit by the state partners. If a hospital had completed an ICAR in the year before STRIVE, they were able to reuse that survey for their baseline assessment. A summary report from these assessments was provided to each site, highlighting opportunities for improvement and a list of STRIVE content and resources to assist in addressing these gaps.Education: Foundational and HAI-Specific Web-Based ModulesSubject-matter experts created educational materials for 12 different topics. Development of educational materials by experts occurred via in-person meetings and work group conference calls. Two primary topic domains were identified around which program education would be focused: foundational and HAI-specific elements.The foundational domain emphasized core infection control practices that are known to have variable compliance but are critical for success of any HAI prevention initiative (for example, hand hygiene, personal protective equipment use, and environmental cleaning). Many are considered "horizontal" infection control strategies in that they affect not one but many pathogens and HAIs. Eight elements for the foundational domain were identified: 1) competency-based training, auditing, and feedback; 2) hand hygiene; 3) personal protective equipment; 4) environmental cleaning; 5) antimicrobial stewardship; 6) making an effective infection prevention business case; 7) patient and family engagement; and 8) socioadaptive strategies for preventing infection.The HAI-specific domains were concentrated on best practices for preventing CDI, CLABSI, CAUTI, and hospital-onset MRSA bloodstream infection. In total, subject-matter experts created 51 short (10 to 20 minutes), Web-based, on-demand educational modules covering key topics in the 2 domains (Appendix Table).Appendix Table. Overview of the 51 Web-Based Learning Modules Developed for the STRIVE ProgramA 2-tiered intervention approach was developed for the HAIs targeted in STRIVE. Tier 1 interventions were defined as basic, evidence-based interventions that every hospital should have in place (for example, ensuring that central lines are placed aseptically). Foundational elements remained a critical aspect across tier 1 for the HAI-specific modules as these elements generally have demonstrated success, are economically efficient, and have multiplicative effects across HAIs. Foundational elements are also crucial to have in place before more complex technical and social interventions are introduced. Tier 2 interventions were generally considered more complex, "advanced" steps for hospitals to take once tier 1 interventions were reliably in place but not leading to a decline in a particular HAI. In general, tier 2 interventions were considered to require increased human and economic capital compared with tier 1.Engaging Sites: Learning Action ForumsIn conjunction with the Web-based modules, monthly learning action forums were hosted by HRET for all cohorts. These monthly, 1-hour webinars were discussion-based and interactive and were built on supporting the didactic content from the curriculum's on-demand courses. They provided hospitals with an opportunity to share their infection prevention strategies, challenges, and successes, thereby strengthening engagement and learning across member sites. The learning action forums also allowed national subject-matter experts to interact with hospitals and answer questions related to webinar content or materials. The lead for most learning action forums was often an infection preventionist or someone with a role in quality at the local hospital. The lead would distribute the webinar information to staff, which typically included nurse managers, environmental services, frontline clinicians, and other clinical and nonclinical staff, depending on the topic of the learning action forum.Education: TAP StrategyThe TAP strategy (15) developed by the CDC can be used not only to identify facilities and units with a high burden of HAIs, but also to highlight gaps in infection prevention. In this way, finite infection prevention resources can be directed to areas of greatest opportunity. The TAP strategy incorporates the TAP reports generated in the CDC's NHSN, along with standardized assessment tools and implementation strategies for CLABSI, CAUTI, and CDI.Feedback from the cohort 1 pilot revealed that additional, more intense education and training on how best to use TAP reports was needed. Although most hospital infection preventionists had heard of the TAP strategy, most lacked in-depth knowledge, and few organizations were actively using TAP resources. Therefore, many state-level in-person meetings incorporated TAP training, provided by their state health departments, to drive increased understanding of this strategy. In addition, from June 2017 to January 2018, the CDC collaborated with HRET to develop and deliver four 90-minute webinars on how to run and interpret TAP reports and use TAP strategies and resources to maximize HAI prevention. To further support state partner knowledge of this valuable resource, the CDC provided a webinar in December 2017 for state partners, providing additional education around how to use TAP reports and strategies at the state level to promote HAI prevention work.Strengthening Partnerships Through Coaching and CollaborationState health departments and SHAs collaborated to support hospitals in administering the PCA or ICAR, interpreting results, and finding resources to address identified gaps. In addition, state health departments were instrumental in educating hospitals on running and using TAP reports, utilizing STRIVE venues, such as in-person meetings and site visits in each state, along with the SHA. In addition, the SHA program lead (and often their health department partners) supported hospitals via monthly one-on-one calls, webinars, or office hours open to all STRIVE hospitals. These touch points were used for shared learning and coaching from the state mentors and experts around barriers and action planning to reach goals. Upon request, subject-matter experts from the national program team would also join such calls to add expertise. The state partners often acted in the role of encourager and cheerleader for teams to support momentum as well.State In-Person MeetingsOn the basis of feedback from cohort 1 pilot sites, state-level in-person meetings were implemented for all participating states in cohorts 2 to 4. Although the online and virtual materials were felt to be helpful, sites in cohort 1 felt that bringing hospitals and state partners together in person was necessary to support building relationships. Such meetings also provided protected time and space for hospital participants' learning and networking with peers as well as state and national experts.ImplementationIn contrast to single-unit interventions often found in infection control projects, the focus of this program was large-system transformation (17) to influence multiple hospitals, organizations, and health care providers. The national program team developed a full STRIVE implementation plan focused on leveraging content for both foundational and HAI-specific practices. The curriculum was divided into 3 phases: onboarding to the STRIVE program, foundational infection prevention strategies, and education targeted to the program's 4 HAIs.In May 2016, onboarding started for cohort 1, which included a general program overview, team formation, and education regarding ICAR/PCA assessments and TAP strategy. The rollout for Web-based modules then occurred for cohort 1 as follows: July to October 2016 (foundational elements modules), November 2016 to January 2017 (HAI-specific tier 1 modules), and February 2017 to March 2017 (HAI-specific tier 2 modules). These modules were available to all subsequent cohorts throughout their 12-month collaborative after their onboarding. Web modules for STRIVE can be found at www.cdc.gov/infectioncontrol/training/strive.html.ConclusionThe STRIVE initiative, coordinated by the HRET and funded by the CDC, brought together state-level organizations with short-stay and long-term acute care hospitals across the country to improve infection prevention and control practices for hospitals with a disproportionately high burden of HAIs. Federal funds for this initiative were in part in response to the lessons learned with Ebola and how stakeholders were interested in strengthening state partnerships and infection control measures in preparation for any future emerging infectious disease. Through the STRIVE initiative, the architecture of preventing HAI shifted from hospital-based to instead utilizing national efforts to effect local improvement efforts in hospitals across the United States.References1. Klevens RM, Edwards JR, Richards CL, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122:160-6. [PMID: 17357358] CrossrefMedlineGoogle Scholar2. National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination. Washington, DC: U.S. Department of Health and Human Services; 23 April 2019. Accessed at https://health.gov/hcq/prevent-hai-action-plan.asp on 6 December 2018. Google Scholar3. 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[PMID: 25230774] doi:10.1186/1472-6963-14-401 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Rush University Medical Center, Chicago, Illinois (K.J.P.)Weill Cornell Medicine, New York, New York (D.P.C.)University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., S.S., V.C.)Health Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.L., A.J.R., L.H.)Disclaimer: The findings and conclusions in this report are those of the authors and do not represent the official position of the CDC, the American Hospital Association, or the Department of Veterans Affairs.Acknowledgment: The authors thank the HRET Health Care-Associated Infection team, as well as the National Program Team and all members of the CDC STRIVE collaborative.Disclosures: Dr. Popovich reports personal fees from CDC contract with HRET during the conduct of the study. Dr. Calfee reports a CDC contract with the HRET, which subcontracted with Weill Cornell Medical College, during the conduct of the study. Dr. Patel, Dr. Saint, and Dr. Chopra report a contract from the CDC with the HRET, which subcontracted with the University of Michigan to support faculty/staff effort for this contract, during the conduct of the study. Dr. Saint also reports personal fees from Doximity and Jvion outside the submitted work. Ms. Lassiter, Mr. Rolle, and Ms. Hung report a CDC contract with HRET during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-3529.Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.Corresponding Author: Kyle J. Popovich, MD, MS, Rush University, 600 South Paulina, Suite 143, Chicago, IL 60612; e-mail, [email protected]edu.Current Author Addresses: Dr. Popovich: Rush University, 600 South Paulina, Suite 143, Chicago, IL 60612.Dr. Calfee: Weill Cornell Medicine, 525 East 68th Street, Box 265, New York, NY 10065.Dr. Patel: VA Ann Arbor Healthcare System, 111-I, 2215 Fuller Road, Ann Arbor, MI 48105.Ms. Lassiter, Mr. Rolle, and Ms. Hung: Center for Health Innovation, American Hospital Association, 155 North Wacker Drive, Suite 400, Chicago, IL 60606.Drs. Saint and Chopra: Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI 48109-2800.Author Contributions: Conception and design: K.J. Popovich, P.K. Patel, A.J. Rolle, L. Hung, S. Saint, V. Chopra.Analysis and interpretation of the data: K.J. Popovich, P.K. Patel.Drafting of the article: K.J. Popovich, L. Hung, V. Chopra.Critical revision of the article for important intellectual content: K.J. Popovich, D.P. Calfee, P.K. Patel, A.J. Rolle, L. Hung, S. Saint, V. Chopra.Final approval of the article: K.J. Popovich, D.P. Calfee, P.K. Patel, S. Lassiter, A.J. Rolle, L. Hung, S. Saint, V. Chopra.Obtaining of funding: S. Saint, V. Chopra.Administrative, technical, or logistic support: D.P. Calfee, S. Lassiter, L. Hung, V. Chopra.Collection and assembly of data: K.J. Popovich.This article is part of the Annals supplement "States Targeting Reduction in Infections via Engagement (STRIVE)," which was supported by the Health Research & Educational Trust and built upon work made possible by the Centers for Disease Control and Prevention, STRIVE Program (contract 200-2015-88275). 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Rolle, MPH, and Vineet Chopra, MD, MSc 1 October 2019Volume 171, Issue 7_SupplementPage: S2-S6KeywordsBacteremiaHealth careInfectious disease controlLong-term careMethicillin-resistant staphylococcus aureusPathogens ePublished: 1 October 2019 Issue Published: 1 October 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...