The BASIC trial: Improving implementation of evidence-based approaches and surveillance to prevent bacterial transmission and infection

We propose to establish a best practice for implementation of a multifaceted approach designed to attenuate
perioperative ESKAPE (Enterococcus, S. aureus, Klebsiella, Acinetobacter, Pseudomonas, Enterobacter spp.)
transmission and associated surgical site infection (SSI) development. Perioperative ESKAPE transmission
(inoculum) contributes to the development of surgical site infections (SSIs) which affect 3-5% of patients
undergoing surgery. SSIs increase patient morbidity, prolong hospitalization, increase the risk of intensive care
unit admission, and increase the risk of death 2-fold. ESKAPE pathogens are particularly problematic.
Sustained reductions in epidemiologically-related, perioperative S. aureus transmission events achieved via a
multi-faceted approach including surveillance feedback optimization resulted in substantial SSI reductions
(88% decrease). An evidence-based approach for attenuation of the perioperative bacterial inoculum2 must
integrate improvements in provider hand hygiene, intravascular catheter design/handling, environmental
cleaning/organization, and patient decolonization. In this application, we propose a type 1 hybrid
effectiveness-implementation using a 2x2 factorial cluster-randomized design guided by RE-AIM. We aim to
identify a best practice for addressing the perioperative ESKAPE inoculum. We will examine the relative
effectiveness of increased site awareness and commitment to generating improvements via technical
assistance (TA), team coaching implementation of an evidence-based set of interventions (EBIP), and TA or
EBIP with ESKAPE transmission surveillance feedback. Our strong preliminary data from a randomized trial
implementing a multifaceted program with surveillance has demonstrated substantial and statistically
significant reductions in transmission of S. aureus and 90-day SSIs and recently reproduced our randomized
trial findings in an additional external site. Therefore, our prior research strongly suggests that the proposed
research should be done and justifies scaling up to dissemination and implementation. Our exceptional
multidisciplinary team is well equipped to successfully complete the proposed trial and aims. In the proposed
trial guided by RE-AIM, we will advance scientific knowledge and inform future dissemination and
implementation by investigating how best to scale-up an already successful multifaceted approach to national
dissemination through either TA or EBIP with or without surveillance. We will conduct a rigorous cost-
effectiveness analysis including evaluation of net cost savings. The proposed trial guided by RE-AIM (Aim 1),
the addition of 1-year follow-up for sustainability (Aim 2), and cost-effectiveness analysis (Aim 3) will provide
the essential scientific knowledge to adopters and organizers to be able to reproduce the most effective
delivery method of our interventions to their local setting in addition to informing our investigative team which
approach to scale-up to reach national dissemination.

Grant Number: 5R01AI155752-05
NIH Institute/Center: NIH
Principal Investigator: Jeremiah Brown