evidence-based practice in infection control and prevention
TRANSCRIPT
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Getting Evidence intoInfection Control Practice
Mary Ann D. Lansang, MD, FPCP, FPSMIDPHICS Convention
May 29, 2015
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Outline• What is Evidence-based Practice (EBP)?• Introduction to key concepts in EBP
o 6 A’so PICOTo RAMBO
• Practice scenario on infection control & prevention• The X factor• Evaluation and quality improvement
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What is Evidence-Based Practice?• The application of the best available research
results (EVIDENCE) when making decisions abouthealth care (from: Agency for Effective Healthcare Research &Quality, USA)
• Evidence is used alongside clinical expertise andpatient preferences
• Local/population context is also important
• Origins from “Evidence-Based Medicine” (Sackett etal. British Medical Journal, 1996)
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Dr David Sackett: father of EBM(1934 – 2015)
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What is Evidence-based Practice?
http://www.cebm.net/
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What is Evidence Based Practice?
http://www.cebm.net/
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Focus of EBP• Focus on outcomes and costs:
o Reduce unnecessary variations in practiceo Close the gap between evidence and practiceo Enable systematic management of information
overload
• Interventions based on evidence havebetter outcomes
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EBP improves patient outcomes
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EBM/EBP Key Concepts
• ‘PICOT’• Patient/s• Intervention/s• Comparison• Outcome/s• Time
• 6 A’s1. ASK2. ACCESS3. APPRAISE4. AGGREGATE5. APPLY6. AUDIT
• RAMBO• Recruitment• Allocation• Maintenance• Measurements
• Blind, or• Objective
measure-ments &processes©
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The 6 A’s -steps of Evidence-Based Practice1. ASK a focused question2. ACCESS - search for epidemiological evidence to help
answer question3. APPRAISE the evidence for its validity, effect size,
precision)4. AGGREGATE the evidence using the triangle,circle,box,x
FRAMEWORK5. APPLY your decision integrating the aggregated evidence
into the trade-off of (i) benefits versus harms;(ii) patientvalues and preferences, (iii) cost –effectiveness and cost-equity,to make an evidence-based decision
6. AUDIT your practice (i.e. check your actual practiceagainst evidence-based practice on a regular basis)].
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Key: Formulate an answerable question from apatient’s (or hospital’s) problem (1)
Problem:• 39 y.o. male is admitted to the hospital for intermittent high-
grade fever and chills since 3 weeks prior to admission• Hemiplegic, with complete spinal cord injury at C6 from a
diving injury in May 2011• Has had multiple pressure sores in sacral area, and healed
with unrecalled antibiotics• 2 days prior to admission: developed a tender, swollen,
fluctuant mass at right gluteal area• Wound C/S showed: MRSA sensitive to clindamycin,
levofloxacin, linezolid and vancomycin; resistant to oxacillin
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Key: Formulate an answerable question from apatient’s (or hospital’s) problem (2)
Problem (cont’d):•The Hospital Infection Control Unit has instituted contactprecautions and advised daily bathing/wipes with 2%chlorhexidine•The patient’s wife asks you: Are these really necessary? Do Ihave to wear gowns and gloves all the time? And do we reallyhave to wipe him with chlorhexidine, which is expensive? Isn’tsoap and water not enough?•You, as the healthcare worker, secretly agree yourself that allthese procedures are too tedious and labor-intensive, and alsocosts the hospital too much.•YOU LOOK FOR THE EVIDENCE ON THE EFFECTIVENESS OF THESE
INTERVENTIONS – e.g., contact precautions
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EBP Step 1: ASK - turn your questioninto 5 parts (PICOT)
1. Participants (patient(s) you want to treat)2. Intervention( or ‘Exposure’ if no intervention )3. Comparison (there is always an alternative! - another
therapy, nothing …4. Outcome (MCID [Minimal Clinically Important Difference] in the Humanly
Important Outcome [Distress, Disability, Dysfunction, Death]
5. Time frame (over which you expect a result)
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Participants
Intervention Group Comparison Group
OutcomesTime
P
I C
OT
PICOT:
the 5 parts of every epidemiological study
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OUR PICOT QUESTION1. Participants (patient(s) you want to treat)2. Intervention( or ‘Exposure’ if no intervention )3. Comparison (there is always an alternative! - another
therapy, nothing …)4. Outcome ( MCID [Minimal Clinically Important Difference] in the
Humanly Important Outcome [Distress,Disability,Dysfunction,Death] )5. Time frame (over which you expect a result)
Among patients with MRSA infections,are contact precautions more effective than
standard precautions inpreventing health-care associated infectionsover the period of a patient’s hospital stay?
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EBP Step 2: ACCESS - search for thebest evidence to answer your question/s
Use the PICOT components to choose search terms
1. Patient(s): MRSA infections2. Intervention: Contact precautions3. Comparison: Standard precautions4. Outcome Prevention of HAI/nosocomial infections5. Time Period of hospital stay
Among patients with MRSA infections,are contact precautions more effective than hand hygiene
in preventing healthcare associated infectionsover the period of a patient’s hospital stay?
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Levels of EvidenceLevel 1: Systematic
review ofrandomized trials
Level 2: Randomized trialor observational study w/
dramatic effect
Level 3: Nonrandomized controlledcohort/follow-up study
Level 4: Case series, case-control studies
Level 5: Mechanism-based reasoning; expert opinion
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Evidence Hierarchy forEnvironmental Infection Control
- from: McDonald & Arduino, CID Jan 2013
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Good Resource for systematic reviews:Special Collections: Cochrane Library
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P
I C
OT
• P
• I
• C
• O
• T
• Recruitment
• Allocation
• Maintenance
• Measurements
• Blind or
• Objectivemeasurements &processes
EBP Step 3: Appraise the evidenceusing RAMBO on the PICOT frame
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Participants
Intervention Group &Comparison Group
Outcomes
Time
QUESTION: VALIDITY: RAMBO
Measurement of outcomes?
P
IG CG
OT
DESIGN:Selection?
Allocation?
Maintenance of allocation?
+ -
+-
A BC D
Representative?
Allocation?- Randomized?- Comparable
groups?
Maintenance?- Treated equally?- Compliant?
Measurements:- Blind?- Objective?
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Participants
Intervention Group &Comparison Group
Outcomes
Time
QUESTION: VALIDITY:
Measurement of outcomes?
P
IG CG
OT
DESIGN:Selection?
Allocation?
Maintenance of allocation?
+ -
+-
A BC D
1. Fair start?
1. Few drop-out’s?
1. Fair finish?
Participants
Intervention Group (IG) &Comparison Group (CG)
Outcome
IG
CG
+ -+- DC
BA
Allocation?
Selection?
Maintenance of allocation?
QUESTION:
Measurement of outcomes?
DESIGN: VALIDITY
1. Fair start?
2. Few drop outs?
3. Fair finish?
Participants
Intervention Group (IG) &Comparison Group (CG)
Outcome
IG
CG
+ -+- DC
BA
Allocation?
Selection?
Maintenance of allocation?
QUESTION:
Measurement of outcomes?
DESIGN: VALIDITY
1. Fair start?
2. Few drop outs?
3. Fair finish?
Participants
Intervention Group (IG) &Comparison Group (CG)
Outcome
IG
CG
+ -+- DC
BA
Allocation?
Selection?
Maintenance of allocation?
QUESTION:
Measurement of outcomes?
DESIGN: VALIDITY
1. Fair start?
2. Few drop outs?
3. Fair finish?
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What about readily accessible practiceguidelines?• From local medical/specialist societies locally and
abroad. Examples:• PHICS• Philippine Society for Microbiology & Infectious Diseases (PSMID)• Asia Pacific Soceity of Infection Control (APSIC)• Society for Healthcare Epidemiology in America (SHEA)
• Databases and general resources. Examples:• Agency for Healthcare Research and Quality (USA): National
Guideline Clearinghouse (www.guideline.gov)• National Institute for Health and Care Excellence (UK): Guidances
(www.nice.org.uk/guidance)• U.S. Centers for Disease Control• World Health Organization
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Caution:Not all guidelines are evidence-based.
Six domains:1. Scope and purpose2. Stakeholder involvement3. Rigor of development4. Clarity of presentation5. Applicability6. Editorial independence
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Example: SHEA guidelines – are they evidence based?
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SHEA guideline update 2014:Strategies to prevent transmission and infection
in acute care hospitals
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Quick access and appraisal results (1)
• Jain R et al. NEJM 2011; 364:1419+: Veterans Affairsinitiative to prevent MRSAinfections
• Before – after observationalstudy (Oct 2007-June 2010)o I: “MRSA bundle”: universal nasal
surveillance for MRSA, contactprecautions for pts colonized/infectedwith MRSA, hand hygiene, institution-wideeffort (1.9 M admissions; 8.3 M pt-days)
o C: period before Oct 2007
• Significant decrease of 62%from pre-interventioninfection rates (1.62 MRSAinfections per 1,000 pt days)to the MRSA interventionperiod (0.62 infections per1,000 pt days)
• Huskins WC et al. NEJM2011; 364: 1407+: The STAR-ICU Trial
• A cluster-randomizedcontrolled trialo I: surveillance for MRSA and VRE
colonization + contact precautions(5,434 admissions in 10 ICUs)
o C: existing hospital practice, whichcould include contact precautionsfor MRSA-infected pts (3,705admission in 8 ICUs)
• 6 months study period• No significant difference in
mean ICU level of incidenceof col’n or infection withMRSA/VRE per 1000 pt-daysat risk (40.3 vs 35.6 events)
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Quick access and appraisal results (2)
• Jain R et al. NEJM 2011; 364:1419+: Veterans Affairsinitiative to prevent MRSAinfections
• All acute care units (exceptpsychiatry
• Inherent limitations of anuncontrolled before-and-after studyo VA system had introduced new
VAP and CLBSI guidelines theprevious year
o Issued a new guidancedocument on MRSAdecolonization 6 months afterstart of intervention
o More awareness andeducation during theintervention period:“institutional cultural change”as part of the MRSA bundle
• Huskins WC et al. NEJM2011; 364: 1407+: The STAR-ICU Trial
• Limited to ICUs• Median compliance to
contact precautions:o Gloves: 82%o Gowns: 77%o Hand hygiene: 69%
• Median compliance tostandard precautions:o Gloves: 72%o Hand hygiene: 62%
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Quick access and appraisal results (1)
• Jain R et al. NEJM 2011; 364:1419+: Veterans Affairsinitiative to prevent MRSAinfections
• Before – after observationalstudy (Oct 2007-June 2010)o I: “MRSA bundle”: universal nasal
surveillance for MRSA, contactprecautions for pts colonized/infectedwith MRSA, hand hygiene, institution-wideeffort (1.9 M admissions; 8.3 M pt-days)
o C: period before Oct 2007
• Significant decrease of 62%from pre-interventioninfection rates (1.62 MRSAinfections per 1,000 pt days)to the MRSA interventionperiod (0.62 infections per1,000 pt days)
• Huskins WC et al. NEJM2011; 364: 1407+: The STAR-ICU Trial
• A cluster-randomizedcontrolled trialo I: surveillance for MRSA and VRE
colonization + contact precautions(5,434 admissions in 10 ICUs)
o C: universal gloving untilsurveillance cultures negative (3,705admission in 8 ICUs)
• 6 months study period• No significant difference in
mean ICU level of incidenceof col’n or infection withMRSA/VRE per 1000 pt-daysat risk (40.3 vs 35.6 events)
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EBP Step 4: AGGREGATE the relevant information &make an evidence-based decision:’ the X-factor
©
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Epidemiologicevidence
Clinical /population
healthconsiderations
Policy issues
Patient / communitypreferences
X-factor: making evidence-based decisions
expertise: ‘putting it all together’ the art ofpractice
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Step 5APPLY your decision
USE THE ‘GRADE’ FrameworkIntegrating• the aggregated evidence• the trade-off of benefits versus harms•patient values and preferences•cost –effectiveness and cost- equity,
to make an evidence-based decision
http://www.gradeworkinggroup.org/publications/index.htm
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Step 6: AUDIT –evaluate & improve performance
1. Determine ‘best’ practice (EBP Steps 1-4)2. Assess current practice: survey3. Compare with best practice - is there a gap?4. Consider reasons for gap, identify processes toreduce gap & implement5. Re-survey: is there any improvement?
= quality improvement / audit
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Recap• Evidence-based Practice (EBP)• Introduction to key concepts in EBP
o 6 A’so PICOTo RAMBO
• Application to an infection control problem: levelsof evidence
• The X factor• Evaluation and quality improvement
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Huge acknowledgments to:For some EBP slides:• Professor Peter Tugwell, Center for Global Health,
University of Ontario, Canada• Carl Heneghan, Center for Evidence Based
Medicine, University of Oxford, UK (www.cebm.net)