Dr. Mary Ann Lansang teaches us how to use the concepts of evidence-based medicine in our daily lives as infection prevention and control practitioners

1. Getting Evidence into
Infection Control Practice
Mary Ann D. Lansang, MD, FPCP, FPSMID
PHICS Convention
May 29, 2015

2. Outline
• What is Evidence-based Practice (EBP)?
• Introduction to key concepts in EBP
o 6 A’s
o PICOT
o RAMBO
• Practice scenario on infection control & prevention
• The X factor
• Evaluation and quality improvement

3. What is Evidence-Based Practice?
• The application of the best available research
results (EVIDENCE) when making decisions about
health care (from: Agency for Effective Healthcare Research &
Quality, USA)
• Evidence is used alongside clinical expertise and
patient preferences
• Local/population context is also important
• Origins from “Evidence-Based Medicine” (Sackett et
al. British Medical Journal, 1996)

4. Dr David Sackett: father of EBM
(1934 – 2015)

5. What is Evidence-based Practice?
http://www.cebm.net/

6. What is Evidence Based Practice?
http://www.cebm.net/

7. Focus of EBP
• Focus on outcomes and costs:
o Reduce unnecessary variations in practice
o Close the gap between evidence and practice
o Enable systematic management of information
overload
• Interventions based on evidence have
better outcomes

8. EBP improves patient outcomes

9. EBM/EBP Key Concepts
• ‘PICOT’
• Patient/s
• Intervention/s
• Comparison
• Outcome/s
• Time
• 6 A’s
1. ASK
2. ACCESS
3. APPRAISE
4. AGGREGATE
5. APPLY
6. AUDIT
• RAMBO
• Recruitment
• Allocation
• Maintenance
• Measurements
• Blind, or
• Objective
measure-
ments &
processes
©

10. The 6 A’s -steps of Evidence-Based Practice
1. ASK a focused question
2. ACCESS - search for epidemiological evidence to help
answer question
3. APPRAISE the evidence for its validity, effect size,
precision)
4. AGGREGATE the evidence using the triangle,circle,box,x
FRAMEWORK
5. APPLY your decision integrating the aggregated evidence
into the trade-off of (i) benefits versus harms;(ii) patient
values and preferences, (iii) cost –effectiveness and cost-
equity,to make an evidence-based decision
6. AUDIT your practice (i.e. check your actual practice
against evidence-based practice on a regular basis)].

11. Key: Formulate an answerable question from a
patient’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

12. Key: Formulate an answerable question from a
patient’s (or hospital’s) problem (2)
Problem (cont’d):
•The Hospital Infection Control Unit has instituted contact
precautions and advised daily bathing/wipes with 2%
chlorhexidine
•The patient’s wife asks you: Are these really necessary? Do I
have to wear gowns and gloves all the time? And do we really
have to wipe him with chlorhexidine, which is expensive? Isn’t
soap and water not enough?
•You, as the healthcare worker, secretly agree yourself that all
these procedures are too tedious and labor-intensive, and also
costs the hospital too much.
•YOU LOOK FOR THE EVIDENCE ON THE EFFECTIVENESS OF THESE
INTERVENTIONS – e.g., contact precautions

13. EBP Step 1: ASK - turn your question
into 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)

14. Participants
Intervention Group Comparison Group
Outcomes
Time
P
I C
O
T
PICOT:
the 5 parts of every epidemiological study

15. OUR PICOT QUESTION
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)
Among patients with MRSA infections,
are contact precautions more effective than
standard precautions in
preventing health-care associated infections
over the period of a patient’s hospital stay?

16. EBP Step 2: ACCESS - search for the
best evidence to answer your question/s
Use the PICOT components to choose search terms
1. Patient(s): MRSA infections
2. Intervention: Contact precautions
3. Comparison: Standard precautions
4. Outcome Prevention of HAI/nosocomial infections
5. Time Period of hospital stay
Among patients with MRSA infections,
are contact precautions more effective than hand hygiene
in preventing healthcare associated infections
over the period of a patient’s hospital stay?

17. Levels of Evidence
Level 1: Systematic
review of
randomized trials
Level 2: Randomized trial
or observational study w/
dramatic effect
Level 3: Nonrandomized controlled
cohort/follow-up study
Level 4: Case series, case-control studies
Level 5: Mechanism-based reasoning; expert opinion

18. Evidence Hierarchy for
Environmental Infection Control
- from: McDonald & Arduino, CID Jan 2013

19. Good Resource for systematic reviews:
Special Collections: Cochrane Library

20. P
I C
O
T
• P
• I
• C
• O
• T
• Recruitment
• Allocation
• Maintenance
• Measurements
• Blind or
• Objective
measurements &
processes
EBP Step 3: Appraise the evidence
using RAMBO on the PICOT frame

21. Participants
Intervention Group &
Comparison Group
Outcomes
Time
QUESTION: VALIDITY: RAMBO
Measurement of outcomes?
P
IG CG
O
T
DESIGN:
Selection?
Allocation?
Maintenance of allocation?
+ -
+
-
A B
C D
Representative?
Allocation?
- Randomized?
- Comparable
groups?
Maintenance?
- Treated equally?
- Compliant?
Measurements:
- Blind?
- Objective?

22. Participants
Intervention Group &
Comparison Group
Outcomes
Time
QUESTION: VALIDITY:
Measurement of outcomes?
P
IG CG
O
T
DESIGN:
Selection?
Allocation?
Maintenance of allocation?
+ -
+
-
A B
C D
1. Fair start?
1. Few drop-out’s?
1. Fair finish?
Participants
Intervention Group (IG) &
Comparison Group (CG)
Outcome
I
G
C
G
+ -
+
- 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
I
G
C
G
+ -
+
- DC
BA
Allocation?
Selection?
Maintenance of allocation?
QUESTION:
Measurement of outcomes?
DESIGN: VALIDITY
1. Fair start?
2. Few drop outs?
3. Fair finish?
ts
n Group (IG) &
Group (CG)
I
G
C
G
+ -
+
- DC
BA
Allocation?
Selection?
Maintenance of allocation?
N:
Measurement of outcomes?
DESIGN: VALIDITY
1. Fair start?
2. Few drop outs?
3. Fair finish?

23. What about readily accessible practice
guidelines?
• 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

24. Caution:
Not all guidelines are evidence-based.
Six domains:
1. Scope and purpose
2. Stakeholder involvement
3. Rigor of development
4. Clarity of presentation
5. Applicability
6. Editorial independence

25. Example: SHEA guidelines – are they evidence based?

26. SHEA guideline update 2014:
Strategies to prevent transmission and infection
in acute care hospitals

27. Quick access and appraisal results (1)
• Jain R et al. NEJM 2011; 364:
1419+: Veterans Affairs
initiative to prevent MRSA
infections
• Before – after observational
study (Oct 2007-June 2010)
o I: “MRSA bundle”: universal nasal
surveillance for MRSA, contact
precautions for pts colonized/infected
with MRSA, hand hygiene, institution-wide
effort (1.9 M admissions; 8.3 M pt-days)
o C: period before Oct 2007
• Significant decrease of 62%
from pre-intervention
infection rates (1.62 MRSA
infections per 1,000 pt days)
to the MRSA intervention
period (0.62 infections per
1,000 pt days)
• Huskins WC et al. NEJM
2011; 364: 1407+: The STAR-
ICU Trial
• A cluster-randomized
controlled trial
o I: surveillance for MRSA and VRE
colonization + contact precautions
(5,434 admissions in 10 ICUs)
o C: existing hospital practice, which
could include contact precautions
for MRSA-infected pts (3,705
admission in 8 ICUs)
• 6 months study period
• No significant difference in
mean ICU level of incidence
of col’n or infection with
MRSA/VRE per 1000 pt-days
at risk (40.3 vs 35.6 events)

28. Quick access and appraisal results (2)
• Jain R et al. NEJM 2011; 364:
1419+: Veterans Affairs
initiative to prevent MRSA
infections
• All acute care units (except
psychiatry
• Inherent limitations of an
uncontrolled before-and-
after study
o VA system had introduced new
VAP and CLBSI guidelines the
previous year
o Issued a new guidance
document on MRSA
decolonization 6 months after
start of intervention
o More awareness and
education during the
intervention period:
“institutional cultural change”
as part of the MRSA bundle
• Huskins WC et al. NEJM
2011; 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 to
standard precautions:
o Gloves: 72%
o Hand hygiene: 62%

29. Quick access and appraisal results (1)
• Jain R et al. NEJM 2011; 364:
1419+: Veterans Affairs
initiative to prevent MRSA
infections
• Before – after observational
study (Oct 2007-June 2010)
o I: “MRSA bundle”: universal nasal
surveillance for MRSA, contact
precautions for pts colonized/infected
with MRSA, hand hygiene, institution-wide
effort (1.9 M admissions; 8.3 M pt-days)
o C: period before Oct 2007
• Significant decrease of 62%
from pre-intervention
infection rates (1.62 MRSA
infections per 1,000 pt days)
to the MRSA intervention
period (0.62 infections per
1,000 pt days)
• Huskins WC et al. NEJM
2011; 364: 1407+: The STAR-
ICU Trial
• A cluster-randomized
controlled trial
o I: surveillance for MRSA and VRE
colonization + contact precautions
(5,434 admissions in 10 ICUs)
o C: universal gloving until
surveillance cultures negative (3,705
admission in 8 ICUs)
• 6 months study period
• No significant difference in
mean ICU level of incidence
of col’n or infection with
MRSA/VRE per 1000 pt-days
at risk (40.3 vs 35.6 events)

30. EBP Step 4: AGGREGATE the relevant information &
make an evidence-based decision:’ the X-factor
©

31. Epidemiologic
evidence
Clinical /
population
health
considerations
Policy issues
Patient / community
preferences
X-factor: making evidence-based decisions
expertise: ‘putting it all together’ the art of
practice

32. Step 5
APPLY your decision
USE THE ‘GRADE’ Framework
Integrating
• 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

33. Step 6: AUDIT –
evaluate & improve performance
1. Determine ‘best’ practice (EBP Steps 1-4)
2. Assess current practice: survey
3. Compare with best practice - is there a gap?
4. Consider reasons for gap, identify processes to
reduce gap & implement
5. Re-survey: is there any improvement?
= quality improvement / audit

34. Recap
• Evidence-based Practice (EBP)
• Introduction to key concepts in EBP
o 6 A’s
o PICOT
o RAMBO
• Application to an infection control problem: levels
of evidence
• The X factor
• Evaluation and quality improvement

35. 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)