Environmental cleaning

A key element of HAI reduction efforts over the past 20 years has been improving and ensuring environmental cleaning practices. Florence Nightingale’s demonstration of the importance of cleanliness within healthcare settings is >170 years old, but like hand hygiene, systematic efforts to improve hospital cleaning practices have been implemented more recently. ^{Reference Fee and Garofalo31} Studies evaluating the effectiveness of cleaning of high-touch surfaces after patient discharge have shown that only ∼50% of surfaces were cleaned. ^{Reference Carling, Parry and Rupp32,Reference Carling, Von Beheren, Kim and Woods33} Application of improvement science principles has improved the consistency of cleaning of hospital-room surfaces and the efficiency of ultraviolet light disinfection. ^{Reference Carling, Parry and Rupp32,Reference Martin, Salsgiver and Bernstein34–Reference Ankrum, Neogi, Morckel, Wilhite, Li and Schaffzin36}

Hand Hygiene

The hand hygiene practices of healthcare personnel (HCP), considered the foundation of all efforts to reduce HAIs, has been a focus of many improvement efforts. Projects have focused on improving hand hygiene in intensive care units (ICUs), inpatient settings and emergency departments. They have addressed the behavior of nurses, physicians, and other HCP groups. Improvement efforts have also spanned the globe addressing infrastructure and societal challenges specific to improving hand hygiene in low- and middle-income countries (LMICs). ^{Reference Holmen, Seneza, Nyiranzayisaba, Nyiringabo, Bienfait and Safdar37–Reference Kallam, Pettitt-Schieber, Owen, Agyare Asante, Darko and Ramaswamy40}

Not long ago, poor hand hygiene behavior of HCWs was the norm, and device-associated infections were an expected complication of inpatient care. Thankfully, much has changed, improving in a stepwise fashion over time. Reports of HCP hand hygiene compliance was frequently very low, 40%–50%. ^{Reference Erasmus, Daha and Brug41} Early projects were able to improve this to 66%–80% through promotion of alcohol-based hand rub use, education, and increased awareness. ^{Reference Pittet, Hugonnet and Harbarth42} Subsequent projects have utilized different methods capable of achieving higher reliability, such as real-time feedback from peers or electronic reminders, that have resulted in sustained hand hygiene above 90%. ^{Reference Linam, Honeycutt, Gilliam, Wisdom and Deshpande43–Reference White, Statile and Conway45}

The ‘Big Four’: CLABSI, CAUTI, VAP, and SSI

Four HAIs are most commonly tracked, and these data are used to assess facilities’ patient safety and care quality: CLABSI, CAUTI, ventilator-associated pneumonia (VAP), and SSI. A common method to prevent these HAIs is control of a patient’s normal flora. Bacterial colonization on the skin of a patient may result in infection when allowed to colonize a catheter or contaminate a surgical wound. Likewise, excessive bacterial colonization of the mouth and oral secretions can increase the risk of VAP. Standardizing patient bathing, procedural skin preparation, and oral care have become important components of efforts to reduce device-associated infections and SSIs. ^{Reference Schaffzin, Harte and Marquette10,Reference Musuuza, Guru and O’Horo46,Reference Yokoe, Anderson and Berenholtz47} Significant rate reduction in each HAI has been achieved through sharing of effective interventions from individual healthcare settings and multicenter collaborations that have utilized improvement science methodology to identify effective practices. ^{Reference Schaffzin, Harte and Marquette10,Reference Pallotto, Piazza and Smith48–Reference de Melo, de Abreu and de Oliveira Santos51}

Prevention bundles

Determinants of HAIs are typically complex and multifactorial, and multimodal changes are required to reduce infections sustainably. ^{Reference Yokoe, Anderson and Berenholtz47} Contrary to most research studies in which a single intervention is tested under very controlled circumstances, improvement science seeks to improve outcomes in real-world settings, often testing multiple interventions simultaneously. Implementing a group of interventions together, as a bundle, has become a global standard. The National Health and Safety Network reported mean ICU CLABSI rates during 2006–2008 of 1.3 to 5.5 per 1,000 line days. ^{Reference Edwards, Peterson and Andrus52,Reference Edwards, Peterson and Mu53} Development and implementation of insertion and maintenance bundles reduced rates to 1.4–2.3 CLABSIs per 1,000 line days in adults and children. ^{Reference Miller, Niedner and Huskins54,Reference Pronovost, Needham and Berenholtz55} Since that time, additional studies have refined these bundles and identified strategies to increase the reliability of bundle elements performance. Projects focusing on high-risk populations (premature neonates, oncology, intestinal failure, and cardiac patients) have implemented interventions addressing population-specific risks to expand CLABSI reduction to these groups as well. ^{Reference Pallotto, Piazza and Smith48,Reference Ormsby, Bukoye and Lajoie56–Reference Gupta, Thomas and Patel58} Once thought to be unachievable, rates below 1 CLABSI per 1,000 line days have become more commonplace. ^{Reference Ormsby, Bukoye and Lajoie56,Reference Erdei, McAvoy, Gupta, Pereira and McGowan59,Reference Lipitz-Snyderman, Needham and Colantuoni60}

The use of more rigorous designs such as factorial design, which utilizes subgroups to simultaneously test multiple variables, can determine the relative impact of different interventions or the interaction of variables on the desired outcome. A multicenter collaborative to reduce CLABSIs in pediatric intensive care units (PICUs) utilized a factorial design and determined that the addition of chlorhexidine scrub and chlorhexidine impregnated sponges were not associated with reduced CLABSIs. ^{Reference Miller, Niedner and Huskins54} Other project designs utilizing control units or cross-over designs can also be employed to increase confidence that changes made result in improved outcomes. A hospital-based project to improve healthcare worker hand hygiene sequentially tested interventions, including real-time reminders of healthcare workers forgetting to perform hand hygiene, on 2 different units. Improvement on each unit occurred only after the interventions were introduced. ^{Reference Linam, Margolis, Atherton and Connelly61}

Although implementing evidence-based bundles can accelerate improvement, it can be difficult to determine which interventions are vital to improvement. From a practical standpoint, ensuring that each bundle component contributes directly to improved outcomes allows for efficient use of resources. However, retrospective studies of small and large databases have failed to identify which factors are necessary and sufficient to yield the desired outcome. ^{Reference Kestle, Holubkov and Douglas Cochrane62,Reference Stulberg, Delaney, Neuhauser, Aron, Fu and Koroukian63} Rather, reliability, the consistency of performing the bundle components at each opportunity, has been found to be an important part of any bundle. ^{Reference Schaffzin, Harte and Marquette10} Improvement science methodology provides for measurement of both reliability and effect on outcome, and applying improvement science principles can ensure a clear association between tested interventions and improvement.

Multicenter collaboratives

The urgency to prevent patient harm necessitates coordinated improvement efforts to increase the speed of learning, implementation, and spread of interventions to reduce HAIs. Multicenter collaboratives are an excellent platform to accelerate improvement through shared resources, learning and accountability. As previously discussed, they can also incorporate methodologic designs capable of more in-depth understanding of the impact of various interventions on improvement and the interaction of local context and culture on the effectiveness of interventions at different sites. Multicenter collaboratives have led to improved healthcare worker hand hygiene and reduced device-associated infections in the intensive care unit. ^{Reference Schaffzin, Harte and Marquette10,Reference Pallotto, Piazza and Smith48,Reference Scherer, Reisinger and Goto64,Reference Berenholtz, Pham and Thompson65} For example, the Solutions for Patient Safety collaborative has reduced CLABSIs (13.7%), CAUTIs (56.6%) and SSIs (16.6%) since 2012. ^{Reference Foster, Ackerman and Hupertz11,66} Another multicenter collaborative of 5 adult hospitals in Brazil reduced CLABSI, CAUTIs and VAPs. ^{Reference de Melo, de Abreu and de Oliveira Santos51} Regular communication and collaboration among collaborative members has been cited as a key factor for their success. ^{Reference Welsh, Flanagan and Hoke67}

Even though reaching zero HAIs may not be achievable, continued efforts to identify novel risk factors and to implement interventions to address them as well as application of improvement science to sustain improvements will continue to push the boundaries of preventable harm.

Effective antimicrobial stewardship implementation

To be effective, antimicrobial stewardship implementation requires not only rapid knowledge transfer to the provider community for adoption of best practices but also the involvement of nurses, patients and families to accelerate organizational, programmatic, and cultural change. Many existing improvement science tools could be utilized to assess and implement programs. For example, individual barriers can be assessed using a knowledge, attitudes, and perceptions (KAP) survey for stakeholders or via the COM-B/Behavior Change Wheel (BCW) framework developed through review and synthesis of 19 existing behaving change frameworks. ^{Reference Michie, van Stralen and West74} The COM-B/BCW framework provides a systematic method for identifying and organizing potential behaviors to a behavior change, selecting the barriers that are most likely to lead to the behavior change in each context and choosing evidence-based behavior change techniques most likely to be effective in overcoming targeted barriers. Prochaska and DiClemente’s transtheoretical model (TTM) is another framework consisting of 5 stages that conceptualize how people change their health behavior. This model has been broadly applied to infection prevention and control demonstrating the value in understanding motives among clinicians to adhere to standard precautions and success with stage-matched interventions. ^{Reference Thampi, Szymczak and Leis75}

Organizational level strengths and barriers are also important to assess. Study outcomes can be evaluated using indicators to assess reach, effectiveness, adoption, implementation, and maintenance of the intervention (RE-AIM framework). ^{Reference Bleasdale, Stienecker, Trivedi, Lewis and Deloney76} A systematic review of antimicrobial stewardship in the ambulatory setting found that considering interactions between people and their workplace, the role of the physical environment and external pressures in antibiotic prescribing may be avenues for improvement. ^{Reference Keller, Tamma and Cosgrove77}

Evidence for using improvement science in antimicrobial stewardship

To our knowledge, few studies have utilized improvement science in the implementation of antimicrobial stewardship programs in any setting. Meeker et al ^{Reference Meeker, Knight and Friedberg78} demonstrated in a randomized controlled trial in 5 outpatient primary care clinics, displaying poster-sized commitment letters (behavioral nudging that influences decision making) in patient examination rooms decreased inappropriate antibiotic prescribing for acute respiratory infections (ARIs). Quintos-Alagheband et al ^{Reference Quintos-Alagheband, Noyola and Makvana79} described developing an antimicrobial stewardship program with sustained reduction in antibiotic prescribing using a multifaceted quality improvement methodology that included a key driver diagram and rapid Plan–Do–Study–Act (PDSA) cycles. ^{Reference Quintos-Alagheband, Noyola and Makvana79} Brink et al ^{Reference Brink, Messina and Feldman80} incorporated results of a pre-implementation provider survey to implement antimicrobial stewardship process measures in a step-wise fashion in a diverse group of South African urban and rural private hospitals.

Yadav et al ^{Reference Yadav, Stahmer, Mistry and May81} incorporated improvement science to address unnecessary antibiotic use for ARIs by existing antimicrobial stewardship programs in emergency departments and urgent care centers at 3 tertiary-care centers. A dynamic adaptation process was utilized to redesign the antimicrobial stewardship programs and interventions tested using a cluster-randomized comparative effectiveness clinical trial. Investigators adapted the CDC Core Elements for Outpatient Antimicrobial Stewardship by incorporating stakeholder interviews, validated provider surveys, workflow analyses and key personnel engagement. ⁸² Data were collected on implementation process outcomes such as acceptability, fidelity, adoption, adaptation, and appropriateness. Results demonstrated that adaptation of the intervention components to the local setting followed by an implementation phase led to high acceptability and adoption of the intervention.

More studies in antimicrobial stewardship program implementation and evaluation through the lens of improvement science are needed to help demonstrate the practical utility of applying these theories and tools to further evolve the field of antimicrobial stewardship and tailor these interventions to a breadth of settings.

In conclusion, improvement science has been utilized to study and improve IP and antimicrobial stewardship efforts, but more work is necessary to control and eliminate HAIs and antimicrobial resistance. As healthcare contexts evolve, those involved in IP and antimicrobial stewardship efforts will be challenged to remain flexible and adaptive. Improvement science may be the answer for practitioners with limited resources and daunting challenges due to its framework and methodology that addresses systems, accounts for context, encourages rapid experimentation, and adjusts to achieve a goal. As the number and type of projects to reduce HAIs and promote antimicrobial stewardship expands, resources to support and coordinate this work will need to follow a similar trajectory. We encourage our colleagues conducting improvement science projects to share their experience, both positive and negative, with each other to promote common knowledge and collaboration to prevent harm. With the SQUIRE guidelines, precedent publications in both fields, and now the platform of ASHE, we look to move closer to our goals together.