Moving behavioral interventions in nursing homes from planning to action: a work system evaluation of a urinary tract infection toolkit implementation.

BACKGROUND: Implementation evaluations based on a hybrid deductive-inductive approach provide a detailed understanding of organizational choices to introduce and implement complex interventions and may help explain implementation success or failure. However, such evaluations may not be feasible due to resource constraints. Qualitative analyses of artifacts collected for other purposes during implementation may represent a cost-effective method to understand program implementation when robust evaluations are not feasible. This study used a work systems evaluation of how nursing homes (NHs) implemented a urinary tract infection (UTI) recognition and management improvement toolkit. METHODS: Thirty NHs participated in a randomized control trial in which intervention NHs (n = 12) were assigned a clinical coach who employed a standard template to structure coach calls with the NH champion. A hybrid inductive-deductive approach, using the Systems Engineering Initiative for Patient Safety (SEIPS) model, characterized three action domains related to (1) engagement of staff and providers, (2) distribution of toolkit elements, and (3) toolkit use. RESULTS: A total of 369 coded segments from 148 coach notes generated by three coaches working with 18 NH champions were examined. Planned changes (n = 203) were more frequent compared to actual changes (n = 169). While most NHs quickly engaged staff and providers, which leadership appeared to support, engagement actions were hindered in some NHs due to champion instability or extended champion or medical director absences. Dissemination of materials to family and providers and distribution of tools to staff occurred quickly in 75% of NHs, although delays were encountered in some NHs, usually because of champion instability. CONCLUSIONS: Implementing NH practice change is challenging, and studies examining actions to support planned versus actual change in this setting are limited. The application of the SEIPS model to coach notes collected during the implementation of a structured behavioral intervention to improve the recognition and management of UTI in NHs generated unique insights into the work system and how staff attempted to implement changes. This study identified several factors that interfered with progression from planning to actual change. Future studies are needed to better understand how to best support change interventions in NHs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03520010 , Registered May 9, 2018.

Syndromic Antibiograms and Nursing Home Clinicians' Antibiotic Choices for Urinary Tract Infections.

Importance: Empirical antibiotic prescribing in nursing homes (NHs) is often suboptimal. The potential for antibiograms to improve empirical antibiotic decision-making in NHs remains poorly understood. Objective: To determine whether providing NH clinicians with a urinary antibiogram improves empirical antibiotic treatment of urinary tract infections (UTIs). Design, Setting, and Participants: This was a survey study using clinical vignettes. Participants were recruited via convenience sampling of professional organization listservs of NH clinicians practicing in the US from December 2021 through April 2022. Data were analyzed from July 2022 to June 2023. Interventions: Respondents were randomized to complete vignettes using a traditional antibiogram (TA), a weighted-incidence syndromic combination antibiogram (WISCA), or no tool. Participants randomized to antibiogram groups were asked to use the antibiogram to empirically prescribe an antibiotic. Participants randomized to the no tool group functioned as controls. Main Outcomes and Measures: Empirical antibiotic selections were characterized as microbiologically (1) active and (2) optimal according to route of administration and spectrum of activity. Results: Of 317 responses, 298 (95%) were included in the analysis. Duplicate responses (15 participants), location outside the US (2 participants), and uninterpretable responses (2 participants) were excluded. Most respondents were physicians (217 respondents [73%]) and had over 10 years of NH practice experience (155 respondents [52%]). A mixed-effects logistic model found that use of the TA (odds ratio [OR], 1.41; 95% CI, 1.19-1.68; P < .001) and WISCA (OR, 1.54; 95% CI, 1.30-1.84; P < .001) were statistically superior to no tool when choosing an active empirical antibiotic. A similarly constructed model found that use of the TA (OR, 1.94; 95% CI, 1.42-2.66; P < .001) and WISCA (OR, 1.7; 95% CI, 1.24-2.33; P = .003) were statistically superior to no tool when selecting an optimal empirical antibiotic. Although there were differences between tools within specific vignettes, when compared across all vignettes, the TA and WISCA performed similarly for active (OR, 1.09; 95% CI, 0.92-1.30; P = .59) and optimal (OR, 0.87; 95% CI, 0.64-1.20; P = .69) antibiotics. Conclusions and Relevance: Providing NH clinicians with a urinary antibiogram was associated with selection of active and optimal antibiotics when empirically treating UTIs under simulated conditions. Although the antibiogram format was not associated with decision-making in aggregate, context-specific effects may have been present, supporting further study of syndromic antibiograms in clinical practice.

Implementation of a Prevention Bundle to Decrease Rates of Staphylococcus aureus Surgical Site Infection at 11 Veterans Affairs Hospitals.

Importance: While current evidence has demonstrated a surgical site infection (SSI) prevention bundle consisting of preoperative Staphylococcus aureus screening, nasal and skin decolonization, and use of appropriate perioperative antibiotic based on screening results can decrease rates of SSI caused by S aureus, it is well known that interventions may need to be modified to address facility-level factors. Objective: To assess the association between implementation of an SSI prevention bundle allowing for facility discretion regarding specific component interventions and S aureus deep incisional or organ space SSI rates. Design, Setting, and Participants: This quality improvement study was conducted among all patients who underwent coronary artery bypass grafting, cardiac valve replacement, or total joint arthroplasty (TJA) at 11 Veterans Administration hospitals. Implementation of the bundle was on a rolling basis with the earliest implementation occurring in April 2012 and the latest implementation occurring in July 2017. Data were collected from January 2007 to March 2018 and analyzed from October 2020 to June 2023. Interventions: Nasal screening for S aureus; nasal decolonization of S aureus carriers; chlorhexidine bathing; and appropriate perioperative antibiotic prophylaxis according to S aureus carrier status. Facility discretion regarding how to implement the bundle components was allowed. Main Outcomes and Measures: The primary outcome was deep incisional or organ space SSI caused by S aureus. Multivariable logistic regression with generalized estimating equation (GEE) and interrupted time-series (ITS) models were used to compare SSI rates between preintervention and postintervention periods. Results: Among 6696 cardiac surgical procedures and 16 309 TJAs, 95 S aureus deep incisional or organ space SSIs were detected (25 after cardiac operations and 70 after TJAs). While the GEE model suggested a significant association between the intervention and decreased SSI rates after TJAs (adjusted odds ratio, 0.55; 95% CI, 0.31-0.98), there was not a significant association when an ITS model was used (adjusted incidence rate ratio, 0.88; 95% CI, 0.32-2.39). No significant associations after cardiac operations were found. Conclusions and Relevance: Although this quality improvement study suggests an association between implementation of an SSI prevention bundle and decreased S aureus deep incisional or organ space SSI rates after TJAs, it was underpowered to see a significant difference when accounting for changes over time.

Implementing and validating a home-infusion central-line-associated bloodstream infection surveillance definition.

OBJECTIVE: Central-line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy is necessary to track efforts to reduce infections, but a standardized, validated, and feasible definition is lacking. We tested the validity of a home-infusion CLABSI surveillance definition and the feasibility and acceptability of its implementation. DESIGN: Mixed-methods study including validation of CLABSI cases and semistructured interviews with staff applying these approaches. SETTING: This study was conducted in 5 large home-infusion agencies in a CLABSI prevention collaborative across 14 states and the District of Columbia. PARTICIPANTS: Staff performing home-infusion CLABSI surveillance. METHODS: From May 2021 to May 2022, agencies implemented a home-infusion CLABSI surveillance definition, using 3 approaches to secondary bloodstream infections (BSIs): National Healthcare Safety Program (NHSN) criteria, modified NHSN criteria (only applying the 4 most common NHSN-defined secondary BSIs), and all home-infusion-onset bacteremia (HiOB). Data on all positive blood cultures were sent to an infection preventionist for validation. Surveillance staff underwent semistructured interviews focused on their perceptions of the definition 1 and 3-4 months after implementation. RESULTS: Interrater reliability scores overall ranged from κ = 0.65 for the modified NHSN criteria to κ = 0.68 for the NHSN criteria to κ = 0.72 for the HiOB criteria. For the NHSN criteria, the agency-determined rate was 0.21 per 1,000 central-line (CL) days, and the validator-determined rate was 0.20 per 1,000 CL days. Overall, implementing a standardized definition was thought to be a positive change that would be generalizable and feasible though time-consuming and labor intensive. CONCLUSIONS: The home-infusion CLABSI surveillance definition was valid and feasible to implement.

Characteristics of telemedicine workflows in nursing homes during the COVID-19 pandemic.

BACKGROUND: The use of telemedicine increased dramatically in nursing homes (NHs) during the COVID-19 pandemic. However, little is known about the actual process of conducting a telemedicine encounter in NHs. The objective of this study was to identify and document the work processes associated with different types of telemedicine encounters conducted in NHs during the COVID-19 pandemic. METHODS: A mixed methods convergent study was utilized. The study was conducted in a convenience sample of two NHs that had newly adopted telemedicine during the COVID-19 pandemic. Participants included NH staff and providers involved in telemedicine encounters conducted in the study NHs. The study involved semi-structured interviews and direct observation of telemedicine encounters and post-encounter interviews with staff and providers involved in telemedicine encounters observed by research staff. The semi-structured interviews were structured using the Systems Engineering Initiative for Patient Safety (SEIPS) model to collect information about telemedicine workflows. A structured checklist was utilized to document steps performed during direct observations of telemedicine encounters. Information from interviews and observations informed the creation of a process map of the NH telemedicine encounter. RESULTS: A total of 17 individuals participated in semi-structured interviews. Fifteen unique telemedicine encounters were observed. A total of 18 post-encounter interviews with 7 unique providers (15 interviews in total) and three NH staff were performed. A 9-step process map of the telemedicine encounter, along with two microprocess maps related to encounter preparation and activities within the telemedicine encounter, were created. Six main processes were identified: encounter planning, family or healthcare authority notification, pre-encounter preparation, pre-encounter huddle, conducting the encounter, and post-encounter follow-up. CONCLUSION: The COVID-19 pandemic changed the delivery of care in NHs and increased reliance on telemedicine services in these facilities. Workflow mapping using the SEIPS model revealed that the NH telemedicine encounter is a complex multi-step process and identified weaknesses related to scheduling, electronic health record interoperability, pre-encounter planning, and post-encounter information exchange, which represent opportunities to improve and enhance the telemedicine encounter process in NHs. Given public acceptance of telemedicine as a care delivery model, expanding the use of telemedicine beyond the COVID-19 pandemic, especially for certain NH telemedicine encounters, could improve quality of care.

Antibiotic postprescribing modification opportunities among nursing home residents treated for urinary tract infection.

OBJECTIVE: To characterize opportunities to postprescriptively modify antibiotic prescriptions initiated for treatment of suspected urinary tract infection (UTI) in nursing homes. DESIGN: Cross-sectional cohort study. METHODS: Data from the health records of residents treated for UTI between 2013 and 2014 in 5 Wisconsin nursing homes were abstracted using a structured approach. Explicit definitions were used to identify whether the prescribed antibiotic could have been stopped, shortened, or changed to a nonfluoroquinolone alternative. Antibiotic treatments appropriately modified by study nursing home providers in real time were not considered modifiable. Identification of >1 potential modification opportunity (eg, stop and shorten) per antibiotic treatment event was permitted. RESULTS: In total, 356 eligible antibiotic treatment courses among 249 unique residents were identified. Only 59 antibiotic courses prescribed for treatment of suspected UTI (16.6%) were not amenable to any modification. Discontinuation of treatment due to lack of signs or symptoms of infection was the most frequently identified potential modification opportunity (66.2%). Although less common, substantial numbers of antibiotic treatment courses were potentially amenable to shortening (34%) or agent change (19%) modifications. If applied in concert at 72 hours after antibiotic initiation, stop and shorten modifications could eradicate up to 1,326 avoidable antibiotic days, and change modifications could remove a 32 remaining avoidable fluoroquinolone days. CONCLUSIONS: Substantial opportunity exists to enhance the quality of antibiotic prescribing for treatment of suspected UTI in nursing homes through postprescriptive review interventions. Additional studies examining how to best design and implement postprescriptive review interventions in nursing homes are needed.

An Implementation Roadmap for Establishing Remote Infectious Disease Specialist Support for Consultation and Antibiotic Stewardship in Resource-Limited Settings.

Infectious Disease (ID)-trained specialists, defined as ID pharmacists and ID physicians, improve hospital care by providing consultations to patients with complicated infections and by leading programs that monitor and improve antibiotic prescribing. However, many hospitals and nursing homes lack access to ID specialists. Telehealth is an effective tool to deliver ID specialist expertise to resource-limited settings. Telehealth services are most useful when they are adapted to meet the needs and resources of the local setting. In this step-by-step guide, we describe how a tailored telehealth program can be implemented to provide remote ID specialist support for direct patient consultation and to support local antibiotic stewardship activities. We outline 3 major phases of putting a telehealth program into effect: pre-implementation, implementation, and sustainment. To increase the likelihood of success, we recommend actively involving local leadership and other stakeholders in all aspects of developing, implementing, measuring, and refining programmatic activities.

Reimagining Infection Control in U.S. Nursing Homes in the Era of COVID-19.

Residents of nursing homes (NHs) are susceptible to infection, and these facilities, particularly those that provide post-acute care services, are high-risk settings for the rapid spread of communicable respiratory and gastrointestinal illnesses, as well as antibiotic-resistant bacteria. The complexity of medical care delivered in most NHs has increased dramatically over the past 2 decades; however, the structure and resources supporting the practice of infection prevention and control in these facilities has failed to keep pace. Rising numbers of infections caused by Clostridioides difficile and multidrug-resistant organisms, as well as the catastrophic effects of COVID-19 have pushed NH infection control resources to a breaking point. Recent changes to federal regulations require NHs to devote greater resources to the facility infection control program. However, additional changes are needed if sustained improvements in the prevention and control of infections and antibiotic resistance in NHs are to be achieved.

Longitudinal survey of antibiotic stewardship practices in Wisconsin nursing homes, before and after a policy change.

The Centers for Medicare and Medicaid mandated that nursing homes implement antibiotic stewardship programs (ASPs) by November 2017. We conducted surveys of Wisconsin nursing-home stewardship practices before and after this mandate. Our comparison of these surveys shows an overall increase in ASP implementation efforts, but it also highlights areas for further improvement.

There and back again: the shape of telemedicine in U.S. nursing homes following COVID-19.

INTRODUCTION: Telemedicine use in nursing homes (NHs) expanded during the COVID-19 pandemic. The objectives of this study were to characterize plans to continue telemedicine among newly adopting NHs and identify factors limiting its use after COVID-19. METHODS: Key informants from 9 Wisconsin NHs that adopted telemedicine during COVID-19 were recruited. Semi-structured interviews and surveys were employed to identify participant perceptions about the value of telemedicine, implementation challenges encountered, and plans and barriers to sustaining its delivery after COVID-19. Directed content analysis and a deductive thematic approach using the Systems Engineering Initiative for Patient Safety (SEIPS) model was used during analyses. Quantitative and qualitative data were integrated to identify participant views on the value of telemedicine and the tools and work system enhancements needed to make telemedicine easier and more effective. RESULTS: All participating NHs indicated a preference to continue telemedicine after COVID-19. Urgent assessments of resident change-in-condition and cognitively based sub-specialty consultations were identified as the encounter types most amenable to telemedicine. Reductions in resident off-site encounters and minimization of resident therapy interruptions were identified as major benefits of telemedicine. Twelve work system enhancements needed to better sustain telemedicine were identified, including improvements to: 1) equipment/IT infrastructure; 2) scheduling; 3) information exchange; and 4) telemedicine facilitators. DISCUSSION: NHs that adopted telemedicine during COVID-19 wish to continue its use. However, interventions that enhance the integration of telemedicine into NH and off-site clinic work systems require changes to existing regulations and reimbursement models to sustain its utilization after COVID-19.

Reliability of nonlocalizing signs and symptoms as indicators of the presence of infection in nursing-home residents.

Antibiotics are among the most common medications prescribed in nursing homes. The annual prevalence of antibiotic use in residents of nursing homes ranges from 47% to 79%, and more than half of antibiotic courses initiated in nursing-home settings are unnecessary or prescribed inappropriately (wrong drug, dose, or duration). Inappropriate antibiotic use is associated with a variety of negative consequences including Clostridioides difficile infection (CDI), adverse drug effects, drug-drug interactions, and antimicrobial resistance. In response to this problem, public health authorities have called for efforts to improve the quality of antibiotic prescribing in nursing homes.

Comparison of criteria for determining appropriateness of antibiotic prescribing in nursing homes.

BACKGROUND: Measuring the appropriateness of antibiotic prescribing in nursing homes remains a challenge. The revised McGeer criteria, which are widely used to conduct infection surveillance in nursing homes, were not designed to assess antibiotic appropriateness. The Loeb criteria were explicitly designed for this purpose but are infrequently used outside investigational studies. The extent to which the revised McGeer and Loeb criteria overlap and can be used interchangeably for tracking antibiotic appropriateness in nursing homes remains insufficiently studied. METHODS: We conducted a cross-sectional chart review study in 5 Wisconsin nursing homes and applied the revised McGeer and Loeb criteria to all nursing home-initiated antibiotic treatment courses. Kappa (κ) statistics were employed to assess level of agreement overall and by treatment indications. RESULTS: Overall, 734 eligible antibiotic courses were initiated in participating nursing homes during the study period. Of 734 antibiotic courses, 372 (51%) satisfied the Loeb criteria, while only 211 (29%) of 734 satisfied the revised McGeer criteria. Only 169 (23%) of 734 antibiotic courses satisfied both criteria, and the overall level of agreement between them was fair (κ = 0.35). When stratified by infection type, levels of agreement between the revised McGeer and Loeb criteria were moderate for urinary tract infections (κ = 0.45), fair for skin and soft-tissue infections (0.36), and slight for respiratory tract infections (0.17). CONCLUSIONS: Agreement between the revised McGeer and Loeb criteria is limited, and nursing homes should employ the revised McGeer and Loeb criteria for their intended purposes. Studies to establish the best method for ongoing monitoring of antibiotic appropriateness in nursing homes are needed.

Optimal Urine Culture Diagnostic Stewardship Practice-Results from an Expert Modified-Delphi Procedure.

BACKGROUND: Urine cultures are nonspecific and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. In this study, we aimed to develop expert guidance on best practices for urine culture diagnostic stewardship. METHODS: A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped into three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed during a virtual meeting, then a second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed. RESULTS: One hundred and sixty-five questions were reviewed. The panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, sending alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional urine cultures and urine white blood cell count as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions. CONCLUSIONS: These 18 guidance statements can optimize use of urine cultures for better patient outcomes.

Implementing daily chlorhexidine gluconate (CHG) bathing in VA settings: The human factors engineering to prevent resistant organisms (HERO) project.

BACKGROUND: Daily use of chlorhexidine gluconate (CHG) has been shown to reduce risk of healthcare-associated infections. We aimed to assess moving CHG bathing into routine practice using a human factors approach. We evaluated implementation in non-intensive care unit (ICU) settings in the Veterans Health Administration. METHODS: Our multiple case study approach included non-ICU units from 4 Veterans Health Administration settings. Guided by the Systems Engineering Initiative for Patient Safety, we conducted focus groups and interviews to capture barriers and facilitators to daily CHG bathing. We measured compliance using observations and skin CHG concentrations. RESULTS: Barriers to daily CHG include time, concern of increasing antibiotic resistance, workflow and product concerns. Facilitators include engagement of champions and unit shared responsibility. We found shortfalls in patient education, hand hygiene and CHG use on tubes and drains. CHG skin concentration levels were highest among patients from spinal cord injury units. These units applied antiseptic using 2% CHG impregnated wipes vs 4% CHG solution/soap. DISCUSSION: Non-ICUs implementing CHG bathing must consider human factors and work system barriers to ensure uptake and sustained practice change. CONCLUSIONS: Well-planned rollouts and a unit culture promoting shared responsibility are key to compliance with daily CHG bathing. Successful implementation requires attention to staff education and measurement of compliance.