Foundational Elements of Infection Prevention in the STRIVE Curriculum
Authors: Payal K. Patel, Kyle J. Popovich, Sue Collier, Shelby Lassiter, Lona Mody, Jessica M. Ameling, Jennifer Meddings
Journal: Annals of Internal Medicine (2019)

Supplement: STRIVE1 October 2019Foundational Elements of Infection Prevention in the STRIVE CurriculumFREEPayal K. Patel, MD, MPH, Kyle J. Popovich, MD, MS, Sue Collier, MSN, RN, Shelby Lassiter, BSN, RN, CPHQ, Lona Mody, MD, MSc, Jessica M. Ameling, MPH, and Jennifer Meddings, MD, MScPayal K. Patel, MD, MPHUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., L.M., J.M.)Search for more papers by this author, Kyle J. Popovich, MD, MSRush University Medical Center, Chicago, Illinois (K.J.P.)Search for more papers by this author, Sue Collier, MSN, RNHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.C., S.L.)Search for more papers by this author, Shelby Lassiter, BSN, RN, CPHQHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.C., S.L.)Search for more papers by this author, Lona Mody, MD, MScUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., L.M., J.M.)Search for more papers by this author, Jessica M. Ameling, MPHUniversity of Michigan Medical School, Ann Arbor, Michigan (J.M.A.)Search for more papers by this author, and Jennifer Meddings, MD, MScUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., L.M., J.M.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-3531 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Despite large-scale interventions and multiple stakeholder involvement, health care–associated infections (HAIs) continue to be a common challenge (1–3). National initiatives to reduce device-associated infections, such as central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI), have been promising (4–7). Pathogen-specific HAIs, such as Clostridioides difficile infection (CDI) and hospital-onset methicillin-resistant Staphylococcus aureus bloodstream infection, are also targets for many HAI prevention programs, yet preventing these and other HAIs often requires the use of cross-cutting methods, such as antimicrobial stewardship and environmental cleaning strategies, to achieve improvements (8, 9).To identify and support hospitals struggling to reduce HAIs, the Centers for Disease Control and Prevention (CDC) funded a national project called STRIVE (States Targeting Reduction in Infections via Engagement) (10) to improve infection prevention practices. Using National Healthcare Safety Network data and partnering with state hospital associations, 443 hospitals in 28 states and the District of Columbia were included in 4 cohorts. The STRIVE initiative utilized a multimodal, facilitated implementation program that included 4 key interventions: a baseline Practice Change Assessment, a tiered approach to HAI prevention, numerous educational materials, and guided facilitation using various modalities for HAI reduction. Subject-matter experts created educational materials in 2 domains: HAI-specific and foundational elements that were considered “horizontal” strategies that can influence many pathogens and HAIs. The HAI-specific educational approach was developed into a 2-tiered evidence-based approach. This article outlines the foundational elements addressed in the educational materials and integrated in the program interventions (Figure). Educational materials were delivered with Web-based, on-demand, educational modules.Figure. Foundational elements of infection prevention in the STRIVE project.The intended audience for all the foundational elements educational modules were infection prevention teams and frontline staff, including nurses and physicians. For the antimicrobial stewardship modules, the intended audience also included pharmacists; for the environmental cleaning modules, the audience also included environmental services. STRIVE = States Targeting Reduction in Infections via Engagement. Download figure Download PowerPoint Foundational ElementsCompetency-Based Training for Infection PreventionA competency is a measurable or observable skill, knowledge, or behavior that can be demonstrated as part of educational or job performance. In infection prevention, assuring competency in best practices can reduce HAI and can be done with onboarding of new staff or through continuing education with existing staff. Recurrent assessment can help identify gaps in infection prevention and strengthen overall hospital preparedness for such scenarios as responding to highly communicable infectious diseases. During the Ebola virus disease outbreak in West Africa, several New York City hospitals had mystery patient drills to help identify possible gaps and found that staff competency with personal protective equipment (PPE) was an actionable weakness that needed to be improved (11). Competency-based training should be performed with various members of the health care team, such as physicians (for example, insertion of a central line), nursing staff (for example, insertion of a urinary catheter), and environmental services (for example, thoroughness of room cleaning) (12–15). Assessing competency of infection prevention practices through audit and feedback has been associated with success in HAI prevention (16–18). Educational content in this element acknowledged that competency-based training should address diverse audiences and be designed to help strengthen hospitals' overall infection prevention practices (11). Tools highlighted in the competency section included frameworks and assessments that can inform gaps in competency, such as the Infection Control Assessment and Response (ICAR) tool (19) and the Targeted Assessment for Prevention framework (20) developed by the CDC, and behavior modeling examples, such as video of managers providing effective feedback (21). The ICAR tool and the Practice Change Assessment (10), which both used competency assessment to evaluate infection prevention, were part of the overall STRIVE intervention.Hand HygieneHand hygiene is the most important element of any infection prevention program. Despite evidence and a clear biological basis that performing hand hygiene prevents HAI, hand hygiene rates are often dismal in all types of health care settings (22–24). One systematic review found that median compliance rates for hand hygiene in hospitals were about 40% (25). Barriers to excellent hand hygiene can include limited access to supplies, skin irritation from disinfectants, and time; however, these can be mitigated through hand hygiene role models and adaptive strategies (26, 27). Technological innovation can also be used to enhance hand hygiene rates (28). Educational materials highlighted the importance of hand hygiene, discussed best practices for it, and presented techniques to improve compliance in ward or intensive care unit (ICU) settings. Tools included training films, visual posters, highlights of published work in this area, and standardized data collection and hand hygiene monitoring forms (Appendix Figure 1) (29, 30).Appendix Figure 1. Example of foundational infection prevention tools provided to STRIVE hospitals: visual poster for hand hygiene.This visual poster is available at www.cdc.gov/handhygiene/campaign/promotional.html (30). STRIVE = States Targeting Reduction in Infections via Engagement. Download figure Download PowerPoint Personal Protective EquipmentEnsuring appropriate use of PPE in health care environments is a cornerstone of infection prevention. Standard precautions are infection prevention practices used to prevent transmission of infectious agents. The effectiveness of these techniques, however, depends on health care workers' adherence to correct use of PPE (31). One study that used video monitoring to evaluate adherence to PPE found that it was used correctly only 34% of the time (32). Standard precautions change according to the expected interaction with the patient (for example, if there is potential for splashes of blood or body substances, then mask and eye protection is recommended) and if the patient is colonized or infected with a known transmissible infectious organism (33). The key takeaway from this section was that improving use of PPE can reduce transmission of infectious agents within the hospital, protect health care workers and patients, and prepare hospitals for possible outbreaks of emerging infectious diseases (34, 35). Several foundational elements can be intertwined to encourage PPE use; these include competency-based training, hand hygiene, adaptive strategies, and engaging patients and families (11, 36, 37). To assist hospitals in gathering and using data to improve PPE use, auditing tools were included in the modules, such as how to analyze PPE data, visual posters, and direct observation checklists (Appendix Figure 2) (38).Appendix Figure 2. Example of foundational infection prevention tools provided to STRIVE hospitals: PPE visual tool for donning and doffing.This visual tool is available at www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf (38). PPE = personal protective equipment; STRIVE = States Targeting Reduction in Infections via Engagement. Download figure Download PowerPoint Environmental HygieneThe hospital environment can play an important role in infection transmission. One study done during a CDI outbreak found that environmental contamination with CDI was prevalent not just in infected patient rooms, but also in physician and nurse work areas and on shared pieces of equipment, such as pulse oximetry finger probes, medication carts, and mobile computers, and personal equipment, such as mobile phones (39, 40). Cleaning protocols are often not in place for portable medical equipment, particularly wheelchairs, which are often colonized with pathogenic bacteria (41, 42). Because infectious agents can last for several months in the hospital environment and be an ongoing source of transmission, effective hospital cleaning and disinfection practices are vital (43). Including environmental services as a part of the infection prevention team can help prepare for outbreaks and reduce risk for HAI (35, 44). Incorporating other foundational elements, such as periodic assessment of competency of environmental cleaning procedures, can also help assure that best practices are in place for the hospital environment. Tools provided in these modules included visual data-sharing tools, fishbone diagrams (45), terminal cleaning checklists (46), and a tool to calculate a thoroughness of disinfection cleaning score (47).Antimicrobial StewardshipAlthough infection prevention interventions help control spread of HAI, antimicrobial stewardship can prevent some infections from occurring altogether and reduce colonization with multidrug-resistant organisms (48, 49). As antimicrobial resistance continues to rise domestically and globally, treatments for bacterial infections, including HAI, are becoming limited (50). For this reason, antimicrobial stewardship has become required by acute care hospitals and long-term care settings by accreditation groups, such as the Joint Commission and the Centers for Medicare & Medicaid Services (51, 52). A CDC study indicates that because of national stewardship efforts, an estimated 619 000 HAIs and 37 000 deaths will be avoided between 2015 and 2020 (50).In particular, CDI prevention is intrinsically intertwined with antimicrobial stewardship. A national study in England found that compared with other infection prevention measures, antimicrobial stewardship had the greatest effect on preventing CDI (53). In this foundational module, tools that could facilitate implementation of stewardship were emphasized and often described how to help build or bolster antimicrobial stewardship programs, common targets for stewardship (such as pneumonia and asymptomatic bacteriuria), and how to construct an effective multidisciplinary antimicrobial stewardship team (54). Available resources included the CDC core elements of antimicrobial stewardship, guidance on addressing multidisciplinary stewardship education and tools that address patient education, such as posters explaining that antibiotics don't work against viruses and sample patient–provider interactions (Appendix Figure 3) (54, 55).Appendix Figure 3. Example of foundational infection prevention tools provided to STRIVE hospitals: visual poster for patient education about antimicrobial stewardship.This visual poster is available at www.cdc.gov/antibiotic-use/community/materials-references/print-materials/index.html (55). STRIVE = States Targeting Reduction in Infections via Engagement. Download figure Download PowerPoint Adaptive StrategiesInfection prevention has 2 modalities: technical and adaptive. Technical interventions can make an impact in a straightforward manner: for example, incorporating alcoholic chlorhexidine in central line kits because it is the most effective type of skin cleanser instead of povidone–iodine. Adaptive strategies help an organization change the culture and influence behaviors that are connected to a culture of safety. These strategies include behavior change–based interventions, human factors engineering, and positive deviance (56–58). One hospital in Brazil instituted a positive deviance intervention to improve hand hygiene in their hospital and found a sustainable improvement in hand hygiene as well as a decrease in HAI (59). This element framed how organizations can use various tools to support the attitudes, values, and behaviors shown to promote infection prevention. One tool introduced in this module was the guide to patient safety (GPS), which is a troubleshooting and interactive guide that was developed for each HAI targeted in this project (58, 60). Key takeaways from this foundational element were that successful HAI prevention starts with planning, introspection, and use of qualitative and quantitative tools.Patient and Family EngagementPatients and families are acutely aware of HAIs and are interested in being a partner in HAI prevention (61, 62). Patient education concerning how to prevent HAIs should be universal and easy to understand; however, a recent multihospital study showed that only 7% of hospitals were very confident that patient-directed CDI education was happening (61, 63). When patients were asked in the same study what the biggest risk factor for recurrence of CDI is, more than one half did not know that it was antibiotic use (63). Active patient engagement can lead to unique interventions and effects. For example, a study found that when an intervention to clean patient hands with chlorhexidine in the ICU was implemented, trends toward reduced CLABSI and CAUTI rates and increased nurse hand-washing rates were observed (64). Another study asked patients who had experienced recurrent CDI to speak with their infectious diseases physician before taking any new antibiotics prescribed by other physicians. Despite the high risk for recurrent CDI in this population, 60% of the antibiotics prescribed for the patients in this high-risk group were considered unnecessary (65). Empowering the patient and their family can foster a culture of safety, reduce the chance of HAI, and improve health care worker infection prevention practices (64–66). Key takeaways from this foundational element included the recognition that patients are essential partners in making care safe, patients can help reduce HAIs from the bedside to the board room by serving on HAI reduction teams, infection prevention education should include patients and families, and such resources as these modules can help expand patient engagement practices in a hospital's infection prevention program (Appendix Figure 3).Business Case for Infection PreventionThe clear value of investing in infection prevention should be established to hospital administrators who are often confronted by numerous pressing issues. Strategies include calculating current attributable cost of HAI at the hospital, potential savings, economic analyses, and prospectively measuring the economic impact of interventions to reduce HAI (67). Leadership support has been associated with success of infection prevention and establishing a comprehensive antimicrobial stewardship program (68, 69). Leadership buy-in propagates patient safety culture in the hospital and can inspire employees at all levels, help form interdisciplinary partnerships, and strategically champion infection prevention at various executive and committee levels (70). Support from the executive level increases chances of achieving true organizational culture change, which often can make or break infection prevention interventions (71). Leadership support also means salary support or financial resources for technological advancements that may be required. Inability to obtain these resources can be barriers for hospital epidemiologists and infection prevention teams. Most important, this section emphasized the value of taking the time and effort to build a business case to engage senior leaders and document the value and impact of cross-cutting education and the importance of working with a diverse team within an organization to maximize the effectiveness of the business case for infection prevention. Within these modules, a template that a team can use to guide development of a business case for infection prevention was also provided.ConclusionIn this national initiative, STRIVE, we identified elements of infection prevention that are broad, effective, and horizontal and can be implemented to positively affect multiple HAIs. These foundational elements formed the basis for the program's educational curriculum and included competency-based training, hand hygiene, use of PPE, best practice environmental hygiene, antimicrobial stewardship, adaptive strategies, patient and family engagement, and a business case for infection prevention. In addition, the STRIVE program reinforced the value of strengthening state partnerships, focusing on basics of infection prevention and identifying site-specific barriers to infection prevention to achieve the goal of zero infections for as many HAIs as possible. 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