Creation of Targeted Tools

To help speed implementation and translation of research findings into practice across the nation, tools, such as online materials, training videos, etc., can be created. Materials developed to train the sites participating in the PCT are good starting places for materials for a broader audience. But again, a health system leader must first recognize the need for the tool, then champion its implementation (pointing to the need to involve these stakeholders in study design).

Case Example: REDUCE MRSA and ABATE Infection Trials

The REDUCE MRSA trial was a large, cluster-randomized pragmatic trial of 43 hospitals (74 adult ICUs) that demonstrated that universal bathing with chlorhexidine and universal nasal decolonization with mupirocin significantly reduced MRSA clinical cultures and all-cause bloodstream infections in adult ICUs.

To support broad implementation and facilitate rapid integration of techniques into routine care in ICUs across the country, investigators made the toolkit with educational materials and documentation widely available (Universal ICU Decolonization: An Enhanced Protocol), offered standardized support, and encouraged local adaptation and collaboration. Septimus et al. note several contributing factors that influenced the success of implementation: “(1) a well-designed toolkit with proven success in a pragmatic clinical trial; (2) a program team, experienced in implementing evidence-based practices, that is responsive to local needs; and (3) an established infrastructure for implementing large quality improvement projects (Septimus et al. 2016)."

The implementation of the REDUCE MRSA trial was informed by Pronovost’s five key components of effective translation of knowledge into practice:

  • A focus on systems rather that the care of individual patients
  • Engagement of local interdisciplinary teams to assume ownership of the improvement project
  • Creation of centralized support for the technical work
  • Encouraging local adaption of the intervention
  • Creating a collaborative culture within the local unit and larger system (Pronovost et al. 2008; Septimus et al. 2016)

Most importantly, the successful and rapid implementation of the toolkit used in REDUCE MRSA demonstrates the ability to rapidly integrate research into clinical care, which is, in essence, the foundation of a learning health system.

The diffusion, dissemination, implementation, and sustainability strategy for REDUCE MRSA is described in the table below.

Strategy Details
Diffusion Publication of key finding in the New England Journal of Medicine in June 2013 (Huang et al. 2013).

Universal decolonization of patients in the ICU using a combination of chlorhexidine (CHG) bathing and intranasal mupirocin significantly reduced methicillin-resistant Staphylococcus aureus (MRSA)–positive clinical cultures by 37% and bloodstream infections from any pathogen by 44%.

Dissemination Within HCS partner: A policy and procedure for universal decolonization for all ICU patients was introduced by the HCS partner (Hospital Corporation of America) to all their hospitals in January 2013, following abstract presentation of trial results at a national meeting.
Implementation Within HCS partner: Nursing prompts from the trial for CHG bathing documentation were modified (removed trial name) and activated across the health system. ICU order sets for mupirocin were made available to all hospitals.

External: Investigators also developed a generalizable toolkit with protocols and instructions for CHG bathing and targeted decolonization for MRSA, and a multistep translation program to implement routine universal decolonization in ICUs.

Sustainability Within HCS partner: Feedback reports of CHG and mupirocin compliance developed and deployed.

External: The toolkit is publically available by the Agency for Healthcare Research and Quality: Universal ICU Decolonization: An Enhanced Protocol.

The Active Bathing to Eliminate Infection (ABATE) Trial is a sister trial of REDUCE MRSA. The goal is to determine if using antiseptic bathing for all patients and nasal ointments for patients harboring methicillin-resistant Staphylococcus aureus (MRSA) reduces multidrug-resistant organisms and bloodstream infections. The setting for this trial is not ICUs, as with the REDUCE MRSA trial, but rather it is being conducted in non-ICU settings. Because there is uncertainty about what effects the intervention will have, the team is holding off on implementation outside of the ICU because there is considerable effort and cost involved in implementation.

The diffusion, dissemination, implementation, and sustainability strategy for the ABATE Infection trial is described in the table below.

Strategy Details
Diffusion Presentation and publication of trial results
Dissemination If trial demonstrates value, health system partner (Hospital Corporation of America) will create a policy and procedure for universal decolonization in general medical/surgical units for all hospitals in their system following abstract presentation of trial results at a national meeting.
Implementation Within healthcare system partner: If trial demonstrates value, nursing queries for CHG bathing documentation will be modified to remove the trial name and be activated across the health system. Mupirocin order sets will be deployed for hospital adoption for MRSA carriers outside the ICU setting.

External: If trial demonstrates value, investigators will develop a generalizable toolkit with protocols and instructions for CHG bathing and decolonization targeted decolonization for MRSA and a multistep translation program to implement routine universal decolonization and targeted nasal decolonization in non-ICU units. Video of protocol highlighting important instructions will be publicly shared.

Sustainability Within healthcare system partner: If trial demonstrates value, feedback reports of CHG and mupirocin compliance will be developed and deployed.

External: The toolkit will be publicly available. The patient bathing video is available on the NIH Collaboratory website.

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REFERENCES

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Huang SS, Septimus E, Kleinman K, et al. 2013. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 368:2255–2265. doi:10.1056/NEJMoa1207290. PMID: 23718152

Pronovost PJ, Berenholtz SM, Needham DM. 2008. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 337:a1714. doi: 10.1136/bmj.a1714. PMID: 18838424.

Septimus E, Hickok J, Moody J, et al. 2016. Closing the translation gap: toolkit-based implementation of universal decolonization in adult intensive care units reduces central line-associated bloodstream infections in 95 community hospitals. Clin Infect Dis. 63:172–177. doi:10.1093/cid/ciw282. PMID: 27143669.

Citation:

Zatzick D, Tuzzio L, Chambers D, et al. Dissemination and Implementation: Creation of Targeted Tools. In: Rethinking Clinical Trials: A Living Textbook of Pragmatic Clinical Trials. Bethesda, MD: NIH Health Care Systems Research Collaboratory. Available at: http://rethinkingclinicaltrials.org/dissemination-implementation-top/creation-of-targeted-tools-2/. Updated August 22, 2017.