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Research Priorities Project, year 2000: The Lone Ranger rides again

2001; Elsevier BV; Volume: 29; Issue: 2 Linguagem: Inglês

10.1067/mic.2001.114194

1527-3296

Elaine Larson, Russell N. Olmsted,

Surgical site infection prevention

“Knowing is not enough; we must apply. Willing is not enough; we must do.”—Goethe One of the hallmarks of a professional specialty is not just the application of a body of knowledge to clinical practice but also the commitment and passion to improve practice through the generation and testing of new knowledge. The specialty of infection prevention and control and applied epidemiology reached a new plateau of professionalism with the formation in 1993 of The APIC Research Foundation. Understandably, one of the first priorities was to raise sufficient money to provide funding for several projects each year, and this was a major emphasis for the Foundation during its first 5 years. Under the able leadership of a visionary president and Board of Trustees and the support of individual and corporate donors, the Foundation successfully completed a business plan and an endowment campaign, “One Million Dollars by 1998,” while at the same time funding more than a dozen projects. In 1999 the Foundation, recognizing the need to expand its mission, was renamed The Research Foundation for Prevention of Complications Associated with Health Care (RF). Remarkable feats in just 6 years! This first phase of the RF, as vital as it was, represented the birth of this new baby, which now must grow through childhood, adolescence, and into maturity. This issue of the Journal includes a landmark study that describes The Research Priorities Project (RPP) of the Foundation and represents what we would characterize as the next step in the growth and development process of the RF. With the recent emphasis on outcomes research, evidence-based practice, medical errors, patient safety, and quality improvement, there is at least one common thread—the application of epidemiologic methods as a scientific foundation for intervening to improve health. Interventional and clinical epidemiology are the tools that can be applied across all of these fields (eg, patient safety, occupational health, and evidence-based practice), and these tools have been most highly honed in the field of infection prevention and control. Although our specialty, however, lays claim to epidemiology as a cornerstone of our practice, we must be prepared to responsibly answer questions such as, “Why have there not been more large, multicenter clinical trials of some of our most basic interventions such as hand hygiene, barrier precautions, or new infection control devices or interventions?” We mention this so that we do not inappropriately take credit for using epidemiologic techniques more often or more successfully than we have. Nevertheless, if any specialty group is positioned with the skill set of clinical and epidemiologic expertise needed to tackle the expanded fields of evidence-based practice and outcomes assessment, it should be infection control professionals (ICPs). We simply suggest that we should ask ourselves why we have not done it better, sooner, more often, and more systematically. With that common thread of epidemiology in mind, Table 1 summarizes the research priorities of several organizations as compared with the RF.Table 1Research and policy priorities from various organizationsPerspectiveSourceDescriptionPriority areasExperts in infection prevention and controlLynch P, Jackson M, Saint S. Research Priorities Project, Year 2000 (AJIC Am J Infect Control 2001;29:73-8)Delphi survey of experts “who have influence on the field of infection surveillance, prevention, and control”Application of behavioral and management sciences to achieve complianceMethods to improve appropriateness of antimicrobial useAntimicrobial resistanceCosts of infections and cost analyses of prevention interventionsEconomic impact of nosocomial infections and other adverse eventsAttendees at international conference on nosocomial infectionsAs aboveSurvey of attendees of session at 4th Decennial International conferenceIdentify effective components to infection prevention and control programs and staffingApplication of behavioral and management sciences to achieve complianceEconomic impact of nosocomial infections and other adverse eventsSurveillance indicators for measuring nosocomial complicationsMethods to improve appropriateness of antimicrobial usePurchasers of health careLeapfrog Group for Patient Safety Rewarding Higher Standards (http://www.leapfroggroup.org)Group of Fortune 500 companies in Wachington, DC, Goal: “mobilize employer purchasing power to initiate breakthrough improvements in safety and overall value of health care to American consumersComputer physician order entryEvidence-based hospital referralICU physician staffingHealth care expertsKohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System (Washington [DC]: National Academy Press; 1999).First report of The Quality of Healthcare in America Project initiated by the Institute of Medicine and charged with developing a strategy that would result in a threshold improvement in quality over the next 10 yearsEstablish national focus about safetyIdentify and learn from errors through mandatory reporting efforts and voluntary effortsRaise standards and expectations from safety improvementsCreate safety systems inside health care organizationsGovernmental agencyAgency for Healthcare Research and Quality: Performance Plans for FY 2000 and 2001 and Performance Report for FY 1999 (http://www.ahrq. gov/about/gpra2001/ exsumm01a.htm)Lead federal agency charged with supporting research to improve the quality of health care, reduce its costs, and broaden access to essential servicesSupport improvements in health outcomesStrengthen quality measurement and improvementIdentify strategies to improve access, foster appropriate use, and reduce unnecessary expendituresPhysiciansNational Patient Safety Foundation Agenda for Research and Development in Patient Safety (http://www.ama- assn.org/med-sci/npsf/ agenda.pdf)A foundation established by American Medical Association as an “independent, nonprofit research and education organization dedicated to the measurable improvement of patient safety in the delivery of health care”Reveal existence, frequency and magnitude of new safety problemsAssess contributions of underlying human or system characteristics to safety problemsAssess prevalence of underlying human or systems characteristics in health care analogous to those known to be arbiters of safety in other industriesDevelop and test approaches to modify human or system characteristicsDevelop and test approaches to maintain patient safety efforts as an integral part of the culture of health care deliveryNurse researchers and scientistsLarson EL, Grady PA, Lunney JR. Interdisciplinary group advises the National Institute of Nursing Research on research opportunities for controlling emerging infections (AJIC Am J Infect Control 1999;27:500-2)Consensus panel of 12 scientists and cliniciansCharacterize infectious disease risks in various settings and populationsDescribe health beliefs and practices related to infectionTransfer and test in home and community settings interventions with demonstrated efficacy in acute carePromote effectiveness of infection prevention and control practices by testing innovations (eg, behavioral/ educational, engineering/technologic, organizational/contextual) Open table in a new tab It is informative to compare the research priorities across organizations, but also within the infection control community. For example, the “experts” in the RPP Delphi panel and the attendees of the 4th Decennial conference agreed on only 3 of the top 5 priority areas: studies related to behavior and compliance (ranked number 1 by experts and number 2 by conference attendees), methods to improve appropriate use of antimicrobials (ranked 2 and 5, respectively), and development of data on economic impact of nosocomial outcomes (ranked 5 and 3, respectively). More broadly, the US National Institutes of Health (NIH) distributed almost $10 billion in fiscal year 1996 for research. The NIH has noted the challenges in setting priorities for funding research.1National Institutes of Health Setting research priorities at the NIH.http://www.nih.gov/news/ResPriority/priority.htmDate: December 7, 2000Google Scholar For example, dedicating a substantial portion of funds simply based on the number of persons affected (eg, the common cold) would underfund study of rare diseases such as ataxia telangiectasia, which has yielded vital information that can be applied more broadly. Moreover, the NIH has wisely chosen against supporting only applied research because basic research can provide profound evidence that can affect many scientific disciplines and the health of the population. A tangible example of this—which will resonate with ICPs—is the discovery of synthetic growth hormone, which arose from basic research and mitigated the need to use pituitary-derived human growth hormone, which has been associated with iatrogenic transmission of the prion that causes Creutzfeldt-Jakob disease. The priorities identified by the RF therefore must be examined in a broad context of both basic and applied health research. Important questions to ask include the following: Are these priorities also recognized by other major groups as relevant and important? Are they attainable? Does our specialty have the skills to conduct the appropriate studies? Are the priorities visionary enough? Our answer to the first 3 questions is an unequivocal “yes”—the priorities are relevant, important, attainable, and we have within the specialty the expertise and resources to do the necessary research, given sufficient commitment on our part. We would like to focus for a moment on the fourth question: whether the RPP priorities are sufficiently visionary to lead our profession and respond to the health care needs of our public. We both feel able to offer some critique because one of us (E. L.) was one of the experts in all rounds of the Delphi survey, one of us currently serves as the secretary for the RF Board of Trustees (R. O.), and we were both present at the 4th Decennial conference meeting during which the priorities were discussed and revisited. Hence, we assume our share of the responsibility and burden for both the strengths and the weaknesses of the prioritized research agenda. We have several concerns about the RPP. First and foremost, the articulated priorities are in many ways identical, or very much like, those that have been eloquently discussed over the past 4 decades. One of the major themes of the first Decennial conference on nosocomial infections was the compelling need to document the efficacy of infection prevention and control practices.2Eickhoff TC Historical perspective: the landmark conference in 1970.Am J Med. 1991; 91: 3S-5SAbstract Full Text PDF PubMed Scopus (6) Google Scholar This theme, along with a focus on antibiotic use, antimicrobial resistance, and the behavioral aspects of infection prevention, were repeated in the next 3 conferences.3Larson E. A retrospective on infection control. Twentieth century-the flame burns.AJIC Am J Infect Control. 1997; 25: 340-349Abstract Full Text PDF PubMed Scopus (14) Google Scholar Evidence-based practice is simply systematically gathering, critically appraising, and incorporating evidence in clinical practice, but we still have major gaps in our evidence. Why is it taking 40 years for us to adequately address these issues? Second, we are giving lip service in our conferences and mission statements to an expanded role in terms of site of practice (beyond the hospital) as well as the content of the practice (beyond infection prevention to other adverse outcomes). But we do not see this expanded role in practice. For example, despite the masthead of AJIC (AJIC: Applied Epidemiology in Health Care Settings and the Community) and the active efforts of some Editorial Board members to find new authors, we rarely receive manuscripts outside the traditional topic of infection control, and when we do, our reviewers suggest that the manuscript is not appropriate for AJIC. We continue to think and practice in the box labeled “infection control professional.” We are not suggesting that this is any less important a role than it ever has been, nor that it is in any way narrow in its focus or responsibility. We are suggesting that there is a gap between what we say we are and intend to be, what the health care system needs from us, and what we are actually doing. A decade ago, Lynch and Jackson4Lynch P Jackson MM Monitoring for nosocomial noninfectious complications.AJIC Am J Infect Control. 1990; 18: 391-398Abstract Full Text PDF PubMed Scopus (3) Google Scholar suggested that our specialty needed to expand to include monitoring for nosocomial noninfectious complications, stating “For more than 6 years, leaders in hospital epidemiology have suggested that epidemiologic methods be applied to the field of quality assurance.” This same quote could be made today, only substituting quality assurance for more “in” terms like evidence-based practice or outcomes research. However, their plea seemed to have fallen on deaf ears, and continues to do so. Perhaps the only thing that will ultimately result in change will be the real and personal threat of job loss. The priorities articulated by the experts in the RPP are reflective of this gap. Yes, there is some indication of an expanded perspective (eg, “nosocomial infections and other nosocomial adverse effects”), but the priorities focus almost exclusively on infections. This in part reflects a selection bias because 2 of the 5 journals from which the Delphi panel members were selected were major infection prevention and control journals. Nevertheless, we must act on the fact that our roles MUST expand if we are to be sufficiently responsive to the needs of the public’s health and the system of care delivery—not to the detriment of our practice and specialty, but to its expansion. We are impressed and grateful for the project completed by the RF and the resultant research agenda set forth because it represents the next major step in the maturation of the Foundation itself and of our profession. A systematic, scholarly process was used to identify needs for research. In addition, like the best of scholarly work, it raises more questions and issues than it resolves. We urge us all to act on the RPP in 2 ways: (1) take the priorities to heart and consider what you, through interdisciplinary multicenter efforts, can do to move the science along and resolve some of the issues that have been hanging over our heads for decades, and (2) use this as an opportunity to examine the basic assumptions, values, and mission with which you practice as a person and with which we function as a specialty. From this thoughtful process, let us identify ways to move beyond our comfort zone to expanded roles, sites, and paradigms. It is disconcerting to recognize that after having spent so long mastering a body of practice and knowledge, we now have to rethink, revamp, and push beyond our current boundaries. Living means struggling and constant change; anything less is death. The RPP could have been written (and essentially was) in 1970 and in every decade until the present. What must be done so that the research priorities of 2010 are not a repeat of these? This is a call to action; we are not sure what all needs to be done, but it is clear that status quo is not viable. We have a few suggestions, but perhaps the best outcome of the RPP is that it causes each of us to reassess and recognize the urgency of the need to move forward. Change incentives for clinicians and researchers to work together and across institutions and organizations. Whether it is professional organizations such as the Society for Healthcare Epidemiology of America, the Infectious Disease Society of America, or APIC, government institutions such as the NIH, the Agency for Healthcare Research and Quality, or the Centers for Disease Control and Prevention, or academic organizations and industry, our systems are geared toward entrepreneurs and the rewards are for individual accomplishment. The researcher is urged to get research grants that provide indirect costs to his or her own school (heaven knows, we do not want to do a multicenter trial, as we would have to split the indirect costs and confront multiple bureaucratic requirements), the clinician is urged not to share infection data or successful ideas with other practitioners because the institution wants to maintain a competitive edge, and the officers of professional organizations go into joint meetings armed with strategies to protect their interests and ensure that the other parties do not get more than they do. This is not the result of individual avarice; we are convinced that professionals indeed want and seek the best for those they serve. However, loyalty to one’s specialty organization, profession, or workplace can actually conflict with efficient and effective productivity when the incentives are such that it is “better” not to collaborate. We do not think that this can be resolved at the individual level. What it will take to make this happen, we do not know, but bringing the problem into the sunshine where it can be openly discussed and examined is a first step. Stop hunkering down and riding the range alone. Actively expand your role and practice beyond infection control, beyond a single health care setting, and beyond your discipline; assess and improve the effectiveness and efficacy of your own practice. Move toward evidence-based practice. That does not necessarily mean work harder. Rather, it means choose carefully to focus on high-priority issues on which you can have an impact (Haley’s old “Surveillance by Objectives”5Haley RW Surveillance by objective: a new priority-directed approach to the control of nosocomial infections. The National Foundation for Infectious Diseases lecture.AJIC Am J Infect Control. 1985; 13: 78-89Abstract Full Text PDF PubMed Scopus (89) Google Scholar expanded to “Practice by Objectives”). Institutions and employers are unlikely to continue paying top dollar for a single result (ie, infection control), particularly when they are not even provided with the evidence of how well the practice works! Ghandi noted that we must be the change we want to see. There is scientifically important information to be examined in the cool, bright light of research, it has not been done, is not being done adequately now, and it has to be done. What is it going to take for us to hear this wake-up call? Progress is limited by the isolated capabilities of each person, let us get together and get moving. The Lone Ranger is dead.