Implementation of strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in U.S. hospitals.

OBJECTIVE: To examine the extent to which the strategies recommended by the National Foundation for Infectious Diseases (NFID)-Centers for Disease Control and Prevention (CDC) co-sponsored workshop, Antimicrobial Resistance in Hospitals: Strategies to Improve Antimicrobial Use and Prevent Nosocomial Transmission of Antimicrobial-Resistant Microorganisms, have been implemented and the relationship between the degree of implementation and hospital culture, leadership, and organizational factors. DESIGN: Survey. SETTING: A representative sample of U.S. hospitals stratified by teaching status, bed size, and geographic region. PARTICIPANTS: Infection control professionals. RESULTS: Surveyed hospitals had implemented strategies to optimize the use of antimicrobials and to detect, report, and prevent transmission of antimicrobial-resistant microorganisms. Multivariate analyses found that hospitals with a greater degree of implementation of the NFID-CDC strategic goals were more likely to have management support, education of staff, and interdisciplinary groups specifically to address these issues; they were also more likely to engage in benchmarking on broader quality of care indicators. CONCLUSIONS: Most surveyed hospitals had implemented some measures to address the NFID-CDC recommendations; however, hospitals need to do much more to improve antimicrobial use and to increase their efforts to detect, report, and control the spread of antimicrobial resistance. A supportive hospital administration must foster a culture of ongoing support, education, and interdisciplinary work groups focused on this important issue to successfully accomplish these goals.

Variation in the use of procedures to monitor antimicrobial resistance in U.S. hospitals.

BACKGROUND: Antimicrobial resistance is a growing clinical and public health crisis. Experts have recommended measures to monitor antimicrobial resistance; however, little is known regarding their use. OBJECTIVE: We describe the use of procedures to detect and report antimicrobial resistance in U.S. hospitals and the organizational and epidemiologic factors associated with their use. METHODS: In 2001, we surveyed laboratory directors (n = 108) from a random national sample of hospitals. We studied five procedures to monitor antimicrobial resistance: (1) disseminating antibiograms to physicians at least annually, (2) notifying physicians of antimicrobial-resistant infections, (3) reporting susceptibility results within 24 hours, (4) using automated testing procedures, and (5) offering molecular typing. Explanatory variables included organizational characteristics and patterns of antimicrobial resistance for oxacillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, quinolone-resistant Escherichia coli, and extended-spectrum beta-lactamase-producing Klebsiella species. Generalized estimating equations accounting for the correlation among outcomes at the facility level were used to identify predictors of the five outcomes. RESULTS: Use of the procedures ranged from 85% (automated testing) to 33% (offering molecular typing) and was related to teaching hospital status (OR, 3.1; CI95, 1.5-6.5), participation of laboratory directors on the infection control committee (OR, 1.7; CI95, 1.1-2.8), and having at least one antimicrobial-resistant pathogen with a prevalence greater than 10% (OR, 2.2; CI95, 1.4-3.3). CONCLUSION: U.S. hospitals underutilize procedures to monitor the spread of antimicrobial resistance. Use of these procedures varies and is related to organizational and epidemiologic factors. Further efforts are needed to increase their use by hospitals.

VA QUERI informatics paper: information technology for clinical guideline implementation: perceptions of multidisciplinary stakeholders.

OBJECTIVE: This multisite study compared the perceptions of three stakeholder groups regarding information technologies as barriers to and facilitators of clinical practice guidelines (CPGs). DESIGN: The study settings were 18 U.S. Veterans Affairs Medical Centers. A purposive sample of 322 individuals participated in 50 focus groups segmented by profession and included administrators, physicians, and nurses. Focus group participants were selected based on their knowledge of practice guidelines and involvement in facility-wide guideline implementation. MEASUREMENTS: Descriptive content analysis of 1,500 pages of focus group transcripts. RESULTS: Eighteen themes clustered into four domains. Stakeholders were similar in discussing themes in the computer function domain most frequently but divergent in other domains, with workplace factors more often discussed by administrators, system design issues discussed most by nurses, and personal concerns discussed by physicians and nurses. Physicians and nurses most often discussed barriers, whereas administrators focused most often on facilitation. Facilitators included guideline maintenance and charting formats. Barriers included resources, attitudes, time and workload, computer glitches, computer complaints, data retrieval, and order entry. Themes with dual designations included documentation, patient records, decision support, performance evaluation, CPG implementation, computer literacy, essential data, and computer accessibility. CONCLUSION: Stakeholders share many concerns regarding the relationships between information technologies and clinical guideline use. However, administrators, physicians, and nurses hold different opinions about specific facilitators and barriers. Health professionals' disparate perceptions could undermine guideline initiatives. Implementation plans should specifically incorporate actions to address these barriers and enhance the facilitative aspects of information technologies in clinical practice guideline use.

Provider adherence to COPD guidelines: relationship to organizational factors.

RATIONALE, AIMS AND OBJECTIVES: A clinical practice guideline for chronic obstructive pulmonary disease (COPD) was implemented in all Veterans Health Administration (VHA) hospitals in the US. The aim of the current analyses is to describe current adherence rates and the organizational factors related to provider adherence to the COPD guideline. METHODS: We administered a survey to key informants that assessed adherence to the COPD guideline, approaches to disseminating and implementing the COPD guideline, providers' views of the COPD guideline and guidelines in general, and attitudes about the organizational climate. RESULTS: Surveys were returned by 242 key informants (58%) at 130 of the 143 VHA hospitals (91%). Adherence to the COPD clinical practice guideline is perceived by quality managers within the VHA to be good. The final multivariable predictor model identified five measures that were related to provider adherence with the COPD guideline (R(2) = 0.43): responsibilities were changed to support adherence to the COPD guideline, physicians believe that guidelines implemented in the past year were applicable to their practice, patient care providers consistently participate in activities to improve the quality of care, the regional network office monitors the pace at which guidelines are implemented, and there is a system to provide feedback on routinely collected guideline adherence data collected in addition to External Peer Review Program data. CONCLUSIONS: Organizations can play an important role in providing a supportive climate to facilitate their providers' adherence to guidelines by implementing processes and culture changes that involve these five measures.

Antimicrobial resistance trends and outbreak frequency in United States hospitals.

We assessed resistance rates and trends for important antimicrobial-resistant pathogens (oxacillin-resistant Staphylococcus aureus [ORSA], vancomycin-resistant Enterococcus species [VRE], ceftazidime-resistant Klebsiella species [K-ESBL], and ciprofloxacin-resistant Escherichia coli [QREC]), the frequency of outbreaks of infection with these resistant pathogens, and the measures taken to control resistance in a stratified national sample of 670 hospitals. Four hundred ninety-four (74%) of 670 surveys were returned. Resistance rates were highest for ORSA (36%), followed by VRE (10%), QREC (6%), and K-ESBL (5%). Two-thirds of hospitals reported increasing ORSA rates, whereas only 4% reported decreasing rates, and 24% reported ORSA outbreaks within the previous year. Most hospitals (87%) reported having implemented measures to rapidly detect resistance, but only approximately 50% reported having provided appropriate resources for antimicrobial resistance prevention (53%) or having implemented antimicrobial use guidelines (60%). The most common resistant pathogen in US hospitals is ORSA, which accounts for many recognized outbreaks and is increasing in frequency in most facilities. Current practices to prevent and control antimicrobial resistance are inadequate.

Are United States hospitals following national guidelines for the analysis and presentation of cumulative antimicrobial susceptibility data?

The National Committee for Clinical Laboratory Standards recently published guidelines for analysis and presentation of cumulative antimicrobial susceptibility test data (antibiograms). We sought to determine how well US hospitals already adhere to standards for antibiogram compilation, and to examine the relationship between hospital characteristics and guideline adherence. We surveyed laboratory directors at 670 hospitals and examined 3 guideline criteria: compilation of an antibiogram, annual updating, and distribution to infection control staff and medical staff yearly; 494 surveys were returned (74%). Almost all of the hospitals surveyed publish an antibiogram (95%, n = 481); however, only 60% (n = 296) met all three criteria. Hospital laboratories meeting criteria were more likely to serve as referral laboratories (OR = 1.82; 95% CI = 1.26-2.63), perform susceptibility testing on site (OR = 4.47; 95% CI = 1.84-10.84), use confirmatory tests to detect extended-spectrum beta-lactamases (OR = 1.8; 95% CI = 1.2-2.6), and have more laboratory personnel per bed (3.0 vs. 2.0 FTEs/bed, p = 0.0031). Adherence to guidelines for preparation and dissemination of antibiograms could be improved. Institutional commitment to high quality, on-site microbiology laboratory services will improve adherence to these guidelines.

Involvement in 12-step programs among persons with dual diagnoses.

Although many people with substance use problems are referred to Alcoholics Anonymous (AA) or Narcotics Anonymous (NA), few studies have examined characteristics of persons who comply with such referrals. In particular, little is known about self-help meeting attendance by persons with dual diagnoses. This study examined rates of AA and NA attendance among 351 persons with dual diagnoses who were treated in a hospital setting. It also explored the relationship between diagnosis and meeting attendance. Ten months after hospitalization, the study participants demonstrated rates of AA or NA attendance that were similar to those of persons who were diagnosed as having substance use disorders without severe mental illness. However, patients with schizophrenia or schizoaffective disorders reported significantly fewer days of AA or NA meeting attendance.

Classifying the effectiveness of Veterans Affairs guideline implementation approaches.

Hospitals use numerous guideline implementation approaches with varying success. Approaches have been classified as consistently, variably, or minimally effective, with multiple approaches being most effective. This project assesses the Department of Veterans Affairs (VA) use of effective guideline implementation approaches. A survey of 123 VA quality managers assessed the approaches used to implement the chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure, and major depressive disorder guidelines. Approaches were categorized based on their effectiveness, and the total number of approaches used was calculated. Commonly used approaches were clinical meetings, summaries, and revised forms. Consistently and minimally effective approaches were used most frequently. Most hospitals used 4-7 approaches. Odds ratios demonstrated that consistently effective approaches were paired with minimally and variably effective approaches. The frequent use of consistently effective approaches and multiple approaches benefits VA adherence. However, VA hospitals should consider selective combinations of approaches to ensure the use of the most effective implementation methods.

What factors influence provider knowledge of a congestive heart failure guideline in a national health care system?

Provider knowledge is a potential barrier to adherence to clinical guidelines. The purpose of this study is to assess the impact of organizational, provider, and guideline factors on provider knowledge of a congestive heart failure (CHF) clinical practice guideline (CPG) in the Veterans Health Administration (VHA) health care system. We developed a survey to investigate institution-level factors influencing the effectiveness of guideline implementation, including characteristics of the guideline, providers, hospital culture and structure, and regional network. Survey participants were quality managers, primary care administrators, and other individuals involved in primary care CPG implementation at 143 VHA hospitals with ambulatory care clinics. Potential explanatory variables were grouped into 11 factors. Multivariate regression models assessed the association between these factors and reported levels of provider knowledge regarding the CHF guideline at the hospital level. Two hundred forty surveys from 126 of 143 (88%) VHA hospitals were returned. Provider knowledge of the CHF guideline was estimated as "great" or "very great" by 58% of respondents. Three predictor factors (dissemination approaches, use of technology in guideline implementation, and hospital culture) were independently associated (P < or = .05) with provider knowledge. Specific variables within these categories that were related to greater knowledge included physician belief that guidelines were applicable to their practice, distribution of guideline summaries, use of guideline storyboards in clinic areas, the use of technology (eg, electronic patient records) in CPG implementation, and establishment of implementation checkpoints and deadlines. Provider knowledge of guidelines is affected by factors at various organizational levels: dissemination approaches, use of technology, and hospital culture. Guideline implementation efforts that target multiple organizational levels may increase provider knowledge.

Does patient-centered care improve provision of preventive services?

OBJECTIVES: While patient-centered care (PCC) is desirable for many reasons, its relationship to treatment outcomes is controversial. We evaluated the relationship between PCC and the provision of preventive services. METHODS: We obtained facility-level estimates of how well each VA hospital provided PCC from the 1999 ambulatory Veterans Satisfaction Survey. PCC delivery was measured by the average percentage of responses per facility indicating satisfactory performance from items in 8 PCC domains: access, incorporating patient preferences, patient education, emotional support, visit coordination, overall coordination of care, continuity, and courtesy. Additional predictors included patient population and facility characteristics. Our outcome was a previously validated hospital-level benchmarking score describing facility-level performance across 12 U.S. Preventive Services Task Force-recommended interventions, using the 1999 Veterans Health Survey. RESULTS: Facility-level delivery of preventive services ranged from an overall mean of 90% compliance for influenza vaccinations to 18% for screening for seat belt use. Mean overall PCC scores ranged from excellent (>90% for the continuity of care and courtesy of care PCC domains) to modest (<70% for patient education). Correlates of better preventive service delivery included how often patients were able to discuss their concerns with their provider, the percent of visits at which patients saw their usual provider, and the percent of patients receiving >90% of care from a VA hospital. CONCLUSION: Improved communication between patients and providers, and continuity of care are associated with increased provision of preventive services, while other aspects of PCC are not strongly related to delivery of preventive services.

Organizational predictors of adherence to ambulatory care screening guidelines.

OBJECTIVE: The purpose of this study was to identify hospital organizational characteristics consistently associated with adherence to multiple clinical practice guidelines (CPGs). We examined the relationship between organizational and patient population characteristics and adherence to three screening CPGs implemented throughout the Veterans Health Administration (VHA). MATERIALS AND METHODS: The study included 114 acute care facilities. Three sources of data were used: 1998 American Hospital Association data, VHA External Peer Review Program data for 1998 and 1999, and the 1999 Veterans Satisfaction Survey. Organizational characteristics likely to affect adherence with the CPGs were classified into five conceptual domains (clinical emphasis, operational capacity, patient population, professionalism, and urbanicity). Organizational characteristics were ranked, based on their standardized beta coefficients in bivariate logistic regressions predicting the likelihood of adherence. Within-domain multivariable logistic analyses assessed the robustness of individual predictors of CPG adherence, controlling for other organizational factors within the same domain. RESULTS: Overall, 46 of 48 relationships in the bivariate logistic analyses were significant, and 43 of these remained significant in the within-domain multivariate analyses. The relative rankings of the variables as predictors of CPG adherence within conceptual domains were also quite consistent. CONCLUSIONS: Strong evidence was found for the importance of specific organizational factors, including mission, capacity, professionalism, and patient population characteristics that influence CPG adherence in a large multi-institutional sample involving multiple provider practices. Research and programs to improve adherence to CPGs and other quality improvement activities in hospitals should incorporate these organizational factors.

Benchmarking Veterans Affairs Medical Centers in the delivery of preventive health services: comparison of methods.

OBJECTIVE: To identify consistent provision of clinical preventive services, we sought to benchmark all acute care Veterans Affairs Medical Centers (VAMCs) against each other nationally on the basis of multiple evidence-based, performance measures to identify facilities performing consistently higher and lower than expected. METHODS: The 1998 Veterans Health Survey assessed the self-reported delivery of evidence-based clinical preventive services in a stratified national sample of 450 ambulatory care patients seen at each VAMC. Proportions appropriately receiving each service within the recommended time interval were calculated for 138 VAMCs. Percentile ranks for each outcome were assigned. Two approaches were used for benchmarking performance. First, a scaled score for each facility was calculated across the set of 12 measures. Second, facilities were ranked based on the sum of the percentile ranks over a range of specific high cutoffs (eg, 70-80%) and above a range of lower cutoffs (eg, 40-50%). Ranking was validated by comparing with deciles of ranks on chart audit (External Peer Review Program, EPRP) data using Kendall's tau-b and chi2 quality-of-fit test. Differences between consistently high adherence (CHA) and low adherence (CLA) facilities were compared using the Wilcoxon rank sum test on 14 VHS and 11 EPRP outcomes. RESULTS: Data from 39,939 patients (67% response rate) were examined. In combination, cutoffs of greater than 50th percentile and greater than 75th percentile rank yielded 12 of 14 VHS and 6 of 11 EPRP measures different between CHA and CLA facilities. The scaled-score approach resulted in 20 CHA and 14 CLA facilities. The sum of outcomes ranked above 50th percentile and over 75th percentile for CHA facilities (n = 17) was 15 or more. The sum of outcomes ranked above the same cutoffs for CLA facilities (n = 16) was 3 or less. EPRP and 1998 VHS data demonstrated that the survey measures and benchmarking approaches were both reliable and valid. Both approaches resulted in multiple differences between CHA and CLA facilities; differences were greater using the percentile rank approach. CONCLUSIONS: The VA has successfully encouraged adoption of evidence-based clinical preventive services throughout its health care system. However, facilities show wide variation in their levels of delivery and can be distinguished on the basis of their consistently high or low levels of adherence. Examining service delivery across multiple performance indicators allows identification of opportunities to improve clinical practice guideline implementation and the delivery of preventive services. This approach identifies model institutions where focused investigation of factors associated with consistent performance may be particularly fruitful.

Physician process and patient outcome measures for diabetes care: relationships to organizational characteristics.

BACKGROUND: Optimal diabetes management relies on providers adhering to evidence-based practice guidelines in the processes of care delivery and patients adhering to self-management recommendations to maximize patient outcomes. PURPOSE: To explore: (1) the degree to which providers adhere to the guidelines; (2) the extent of glycemic, lipid, and blood pressure control in patients with diabetes; and (3) the roles of organizational and patient population characteristics in affecting both provider adherence and patient outcome measures for diabetes. DESIGN: Secondary data analysis of provider adherence and patient outcome measures from chart reviews, along with surveys of facility quality managers. SAMPLE: We sampled 109 Veterans Affairs medical centers (VAMCs). RESULTS: Analyses indicated that provider adherence to diabetes guidelines (ie, hemoglobin A1c, foot, eye, renal, and lipid screens) and patient outcome measures (ie, glycemic, lipid, and hypertension control plus nonsmoking status) are comparable or better in VAMCs than reported elsewhere. VAMCs with higher levels of provider adherence to diabetes guidelines had distinguishing organizational characteristics, including more frequent feedback on diabetes quality of care, designation of a guideline champion, timely implementation of quality-of-care changes, and greater acceptance of guideline applicability. VAMCs with better patient outcome measures for diabetes had more effective communication between physicians and nurses, used educational programs and Grand Rounds presentations to implement the diabetes guidelines, and had an overall patient population that was older and with a smaller percentage of black patients. CONCLUSIONS: Healthcare organizations can adopt many of the identified organizational characteristics to enhance the delivery of care in their settings.