Finding the match between healthcare worker and expert for optimal audit and feedback on antimicrobial resistance prevention measures.

BACKGROUND: The potentials of audit and feedback (AF) to improve healthcare are currently not exploited. To unlock the potentials of AF, this study focused on the process of making sense of audit data and translating data into actionable feedback by studying a specific AF-case: limiting antimicrobial resistance (AMR). This was done via audit and feedback of AMR prevention measures (APM) that are executed by healthcare workers (HCW) in their day-to-day contact with patients. This study's aim was to counterbalance the current predominantly top-down, expert-driven audit and feedback approach for APM, with needs and expectations of HCW. METHODS: Qualitative semi-structured interviews were held with sixteen HCW (i.e. physicians, residents and nurses) from high-risk AMR departments at a regional hospital in The Netherlands. Deductive coding was succeeded by open and axial coding to establish main codes, subcodes and variations within codes. RESULTS: HCW demand insights from audits into all facets of APM in their working routines (i.e. diagnostics, treatment and infection control), preferably in the form of simple and actionable feedback that invites interdisciplinary discussions, so that substantiated actions for improvement can be implemented. AF should not be seen as an isolated ad-hoc intervention, but as a recurrent, long-term, and organic improvement strategy that balances the primary aims of HCW (i.e. improving quality and safety of care for individual patients and HCW) and AMR-experts (i.e. reducing the burden of AMR). CONCLUSIONS: To unlock the learning and improvement potentials of audit and feedback, HCW' and AMR-experts' perspectives should be balanced throughout the whole AF-loop (incl. data collection, analysis, visualization, feedback and planning, implementing and monitoring actions). APM-AF should be flexible, so that both audit (incl. collecting and combining the right data in an efficient and transparent manner) and feedback (incl. persuasive and actionable feedback) can be tailored to the needs of various target groups. To balance HCW' and AMR-experts' perspectives a participatory holistic AF development approach is advocated.

Mid-term post-fire losses of nitrogen and phosphorus by overland flow in two contrasting eucalypt stands in north-central Portugal.

Wildfires affect vast areas of Mediterranean forests, thereby triggering changes in hydrological and geomorphological processes that can negatively affect both terrestrial and aquatic ecosystems. Although several studies have evaluated the post-fire hydrological and erosive response in burnt forest areas, an important knowledge gap remains with respect to nutrient mobilization by overland flow. To address this gap, a recently burnt area was selected near the Ermida village (north-central Portugal). The study area was instrumented shortly after a wildfire that occurred in July 2010, to evaluate the export of dissolved (nitrate - NO3-N and orthophosphate - PO4-P) and total nitrogen (TN) and phosphorus (TP) forms by overland flow. This was done in two burnt eucalyptus plantations due to their contrasting slope aspects (south-east vs. north-west). Bounded micro-plots were installed in August 2010 and monitored over two years. During this period, overland flow samples were collected on a 1- to 2-weekly basis, depending on the occurrence of rain. Results showed that the north west-facing slope (BE-N) presented higher nutrient losses than the south east-facing slope (BE-S), contradicting the findings of previous studies in the Mediterranean region. A logging operation that had taken place at the BE-N site shortly before the fire might account for these findings, by causing soil compaction and/or reducing the protective vegetation and litter cover. TN and TP exports were particularly pronounced during the first four months following the wildfire. After this initial period, further peaks in TN and TP exports occurred sporadically, mainly associated to intense rainfall events. The observed mid-term post-fire nutrient losses not only suggested a threat to the soil nutrient balance of Mediterranean eucalypt forests but also a potential risk of eutrophication of downstream water bodies.

Impacts of climate and land use changes on the water quality of a small Mediterranean catchment with intensive viticulture.

Studies that address the potential effects of climate and land use changes on surface water quality are scarce in the Mediterranean region. In the present work, the impacts of climate and land use changes on nutrient and copper exports from a humid Mediterranean catchment (São Lourenço) were evaluated using the SWAT model. SWAT reproduced reasonably well total nitrogen (TN), phosphorus (TP) and copper (Cu) exports in São Lourenço, providing an adequate baseline scenario as well as a suitable model parameterization for assessing the impacts of climate and land use changes under the A1B and B1 emission scenarios for the end of the 21st century (2071-2100). Land use changes scenarios were generated along the same storylines as climate change scenarios to assess the combined effects of the two stressors. Climate changes itself led to a decline in annual TN and TP exports under both emission scenarios mostly due to a decrease in runoff and erosion induced by a reduction in rainfall, but it hardly affected Cu exports largely due to its strong immobilization in soils. Land use changes per se resulted in an increase in streamflow, but the changes in water quality varied markedly according to the scenarios. A substantial decrease in TN, TP and Cu exports was observed under scenario A1B, due to a reduction in vineyard areas. Under scenario B1, however, TP exports decreased much less while TN exports hardly changed, reflecting differences in the preferential transport pathways of these compounds. Cu exports also remained the same, as no changes occurred in the vineyard areas. The combination of climate and land use change scenarios revealed additive impacts on the exports of all three contaminants, emphasizing the importance of integrated approaches to define adaptive land management practices that can ensure the future sustainability of Mediterranean water resources.

Phosphorus loss from a mixed land use catchment in northwest Spain.

This work examined P loss from a mixed land use catchment in northwest Spain and how it was related to hydrological factors. A stream draining a mixed land use catchment of 16 km in northwest Spain was monitored for 5 yr. Water samples were taken more frequently with increased stream flows. A total of 132 runoff events of different magnitudes were analyzed in this study. Mean annual P loss from the catchment was 11.5 kg km, about 68% being transported during runoff events, which only contributed to 29% of the flow. The contribution of runoff events to particulate P and dissolved P losses was 76 and 46% of total losses during the study period, respectively. A high interannual variability in P loss was observed, the differences being related to rainfall amount and distribution. At a seasonal scale, the highest P loads and concentrations were observed during rainy seasons; the lowest P loads occurred in summer because they occurred with stream flow. Particulate P accounted for the greatest proportion (74%) of transported P. There was a high variability in P transported between runoff events, with maximum discharge and discharge increase being the most important variables explaining total P concentration in these events through their effect on suspended sediment concentration.