Improving shared decision-making around antimicrobial-prescribing during the end-of-life period: a qualitative study of Veterans, their support caregivers and their providers.

Objective: Antimicrobials are frequently used for palliation during end-of-life care, but adverse effects, such as antimicrobial resistance, are a concern. Shared decision-making is beneficial in end-of-life care conversations to help align antimicrobial-prescribing with patient preferences. However, there is limited data regarding optimal incorporation of antimicrobial-prescribing discussions into shared decision-making conversations. We explored healthcare provider, patient, and support caregiver (eg, family member/friend) perceptions of barriers and facilitators to discussing antimicrobial-prescribing during the end-of-life period. Design: Qualitative study. Participants: Healthcare providers; palliative care/hospice care patients/caregivers. Methods: We conducted semi-structured interviews on shared attitudes/beliefs about antimicrobial-prescribing during end-of-life patient care at one acute-care and one long-term-care facility. Interviews were analyzed for thematic content. Results: Fifteen providers and 13 patients/caregivers completed interviews. Providers recognized the potential benefit of leveraging shared decision-making to guide antimicrobial-prescribing decisions. Barriers included limited face-to-face time with the patient and uncertainty of end-of-life prognosis. Patients/caregivers cited trust, comprehension, and feeling heard as important characteristics which act as facilitators in fostering effective shared decision-making around antimicrobial use. Communication in which providers ensure patients are involved in shared decision-making discussions could be increased to ensure patients and their providers develop a mutually agreeable care plan. Conclusions: Shared decision-making is a practice that can guide antimicrobial-prescribing decisions during end-of-life care, thus potentially minimizing antimicrobial-related adverse effects. Our findings highlight opportunities for increased shared decision-making around antimicrobial use during end-of-life care. Interventions designed to address the identified barriers to shared decision-making have the potential to improve antimicrobial-prescribing practices at end-of-life.

Antimicrobial physician and pharmacist experience and perception of an antimicrobial Self-Stewardship Time-Out Program (SSTOP) intervention at eight Veterans' Affairs medical centers.

We explored experiences and perceptions surrounding the Self-Stewardship Time-Out Program (SSTOP) intervention across implementation sites to improve antimicrobial use. Semistructured qualitative interviews were conducted with Antibiotic Stewardship physicians and pharmacists, from which 5 key themes emerged. SSTOP may serve to achieve sustainable promotion of antibiotic use improvements.

Association of entry into hospice or palliative care consultation during acute care hospitalization with subsequent antibiotic utilization.

OBJECTIVE: We aimed to estimate antibiotic use during the last 6 months of life for hospitalized patients under hospice or palliative care and identify potential targets (i.e. time points) for antibiotic stewardship during the end-of-life period. METHODS: We conducted a retrospective cohort study of nationwide Veterans Affairs (VA) patients who died between January 1, 2014 and December 31, 2019 and who had been hospitalized within 6 months prior to death. Data from the VA's integrated electronic medical record were collected, including demographics, comorbid conditions, and duration of inpatient antibiotics administered, along with outpatient antibiotics dispensed. A propensity score-matched cohort analysis was conducted to compare antibiotic use between hospitalized patients placed into palliative care or hospice matched to hospitalized patients not receiving palliative care or hospice. RESULTS: There were 9808 and 40 796 propensity score-matched patient pairs in the hospice and palliative care groups, respectively. Within 14 days of placement or consultation, 41% (4040/9808) of hospice patients and 48% (19 735/40 796) of palliative care patients received at least one antibiotic, while 25% (2420/9808) matched nonhospice and 27% (10 991/40 796) matched nonpalliative care patients received antibiotics. Entry into hospice was independently associated with a 12% absolute increase in antibiotic prescribing, and entry into palliative care was associated with a 17% absolute increase during the 14 days post-entry vs. pre-entry period. DISCUSSION: We observed that patients receiving end-of-life care had high levels of antibiotic exposure across this VA population, particularly during admissions when they received hospice or palliative care consultation.

"Our job is to break that chain of infection": Challenges environmental management services (EMS) staff face in accomplishing their critical role in infection prevention.

Objectives: Contaminated surfaces in healthcare settings contribute to the transmission of nosocomial pathogens. Adequate environmental cleaning is important for preventing the transmission of important pathogens and reducing healthcare-associated infections. However, effective cleaning practices vary considerably. We examined environmental management services (EMS) staff experiences and perceptions surrounding environmental cleaning to describe perceived challenges and ideas to promote an effective environmental services program. Design: Qualitative study. Participants: Frontline EMS staff. Methods: From January to June 2019, we conducted individual semistructured interviews with key stakeholders (ie, EMS staff) at 3 facilities within the Veterans' Affairs Healthcare System. We used the Systems Engineering Initiative for Patient Safety (SEIPS) framework (ie, people, environment, organization, tasks, tools) to guide this study. Interviews were audio-recorded, transcribed, and analyzed for thematic content. Results: In total, 13 EMS staff and supervisors were interviewed. A predominant theme that emerged were the challenges EMS staff saw as hindering their ability to be effective at their jobs. EMS staff interviewed felt they understand their job requirements and are dedicated to their work; however, they described challenges related to feeling undervalued and staffing issues. Conclusions: EMS staff play a critical role in infection prevention in healthcare settings. However, some do not believe their role is recognized or valued by the larger healthcare team and leadership. EMS staff provided ideas for improving feelings of value and job satisfaction, including higher pay, opportunities for certifications and advancement, as well as collaboration or integration with the larger healthcare team. Healthcare organizations should focus on utilizing these suggestions to improve the EMS work climate.

Investigation of factors influencing inpatient antibiotic prescribing decisions in the Veterans' Health Administration.

To investigate factors that influence antibiotic prescribing decisions, we interviewed 49 antibiotic stewardship champions and stakeholders across 15 hospitals. We conducted thematic analysis and subcoding of decisional factors. We identified 31 factors that influence antibiotic prescribing decisions. These factors may help stewardship programs identify educational targets and design more effective interventions.

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.

A survey of infection control strategies for carbapenem-resistant Enterobacteriaceae in Department of Veterans' Affairs facilities.

A survey of Veterans' Affairs Medical Centers on control of carbapenem-resistant Enterobacteriaceae (CRE) and carbapenem-producing CRE (CP-CRE) demonstrated that most facilities use VA guidelines but few screen for CRE/CP-CRE colonization regularly or regularly communicate CRE/CP-CRE status at patient transfer. Most respondents were knowledgeable about CRE guidelines but cited lack of adequate resources.

Strategies for the implementation of a nasal decolonization intervention to prevent surgical site infections within the Veterans Health Administration.

As part of a multicenter evidence-based intervention for surgical site infection prevention, a qualitative study was conducted with infection control teams and surgical staff members at three Department of Veterans Affairs Healthcare Systems in the USA. This study aimed to identify strategies used by nurses and other facility champions for the implementation of a nasal decolonization intervention. Site visit observations and field notes provided contextual information. Interview data were analyzed with inductive and deductive content analysis. Interview data was mapped to the Expert Recommendations for Implementing Change (ERIC) compilation of implementation strategies. These strategies were then considered in the context of power and relationships as factors that influence implementation. We found that implementation of this evidence-based surgical site infection prevention intervention was successful when nurse champions drove the day-to-day implementation. Nurse champions sustained implementation strategies through all phases of implementation. Findings also suggest that nurse champions leveraged the influence of their role as champion along with their understanding of social networks and relationships to help achieve implementation success. Nurse champions consciously used multiple overlapping and iterative implementation strategies, adapting and tailoring strategies to stakeholders and settings. Commonly used implementation categories included: "train and educate stakeholders," "use evaluative and iterative strategies," "adapt and tailor to context," and "develop stakeholder interrelationships." Future research should examine the social networks for evidence-based interventions by asking specifically about relationships and power dynamics within healthcare organizations. Implementation of evidence-based interventions should consider if the tasks expected of a nurse champion fit the level of influence or power held by the champion. Trial registration: ClinicalTrials.gov, identifier: NCT02216227.

Evaluation of carbapenem-resistant Enterobacteriaceae (CRE) guideline implementation in the Veterans Affairs Medical Centers using the consolidated framework for implementation research.

BACKGROUND: Infections caused by carbapenem-resistant Enterobacteriaceae (CRE) and carbapenemase-producing (CP) CRE are difficult to treat, resulting in high mortality in healthcare settings every year. The Veterans Health Administration (VHA) disseminated guidelines in 2015 and an updated directive in 2017 for control of CRE focused on laboratory testing, prevention, and management. The Consolidated Framework for Implementation Research (CFIR) framework was used to analyze qualitative interview data to identify contextual factors and best practices influencing implementation of the 2015 guidelines/2017 directive in VA Medical Centers (VAMCs). The overall goals were to determine CFIR constructs to target to improve CRE guideline/directive implementation and understand how CFIR, as a multi-level conceptual model, can be used to inform guideline implementation. METHODS: Semi-structured interviews were conducted at 29 VAMCs with staff involved in implementing CRE guidelines at their facility. Survey and VHA administrative data were used to identify geographically representative large and small VAMCs with varying levels of CRE incidence. Interviews addressed perceptions of guideline dissemination, laboratory testing, staff attitudes and training, patient education, and technology support. Participant responses were coded using a consensus-based mixed deductive-inductive approach guided by CFIR. A quantitative analysis comparing qualitative CFIR constructs and emergent codes to sites actively screening for CRE (vs. non-screening) and any (vs. no) CRE-positive cultures was conducted using Fisher's exact test. RESULTS: Forty-three semi-structured interviews were conducted between October 2017 and August 2018 with laboratory staff (47%), Multi-Drug-Resistant Organism Program Coordinators (MPCs, 35%), infection preventionists (12%), and physicians (6%). Participants requested more standardized tools to promote effective communication (e.g., electronic screening). Participants also indicated that CRE-specific educational materials were needed for staff, patient, and family members. Quantitative analysis identified CRE screening or presence of CRE as being significantly associated with the following qualitative CFIR constructs: leadership engagement, relative priority, available resources, team communication, and access to knowledge and information. CONCLUSIONS: Effective CRE identification, prevention, and treatment require ongoing collaboration between clinical, microbiology, infection prevention, antimicrobial stewardship, and infectious diseases specialists. Our results emphasize the importance of leadership's role in promoting positive facility culture, including access to resources, improving communication, and facilitating successful implementation of the CRE guidelines.

"The role as a champion is to not only monitor but to speak out and to educate": the contradictory roles of hand hygiene champions.

BACKGROUND: Implementation science experts define champions as "supporting, marketing, and driving through an implementation, overcoming indifference or resistance that the intervention may provoke in an organization." Many hospitals use designated clinical champions-often called "hand hygiene (HH) champions"-typically to improve hand hygiene compliance. We conducted an ethnographic examination of how infection control teams in the Veterans Health Administration (VHA) use the term "HH champion" and how they define the role. METHODS: An ethnographic study was conducted with infection control teams and frontline staff directly involved with hand hygiene across 10 geographically dispersed VHA facilities in the USA. Individual and group semi-structured interviews were conducted with hospital epidemiologists, infection preventionists, multi-drug-resistant organism (MDRO) program coordinators, and quality improvement specialists and frontline staff from June 2014 to September 2017. The team coded the transcripts using thematic content analysis content based on a codebook composed of inductive and deductive themes. RESULTS: A total of 173 healthcare workers participated in interviews from the 10 VHA facilities. All hand hygiene programs at each facility used the term HH champion to define a core element of their hand hygiene programs. While most described the role of HH champions as providing peer-to-peer coaching, delivering formal and informal education, and promoting hand hygiene, a majority also included hand hygiene surveillance. This conflation of implementation strategies led to contradictory responsibilities for HH champions. Participants described additional barriers to the role of HH champions, including competing priorities, staffing hierarchies, and turnover in the role. CONCLUSIONS: Healthcare systems should consider narrowly defining the role of the HH champion as a dedicated individual whose mission is to overcome resistance and improve hand hygiene compliance-and differentiate it from the role of a "compliance auditor." Returning to the traditional application of the implementation strategy may lead to overall improvements in hand hygiene and reduction of the transmission of healthcare-acquired infections.

Effect of Frequency of Changing Point-of-Use Reminder Signs on Health Care Worker Hand Hygiene Adherence: A Cluster Randomized Clinical Trial.

Importance: Although hand hygiene (HH) is considered the most effective strategy for preventing hospital-acquired infections, HH adherence rates remain poor. Objective: To examine whether the frequency of changing reminder signs affects HH adherence among health care workers. Design, Setting, and Participants: This cluster randomized clinical trial in 9 US Department of Veterans Affairs acute care hospitals randomly assigned 58 inpatient units to 1 of 3 schedules for changing signs designed to promote HH adherence among health care workers: (1) no change; (2) weekly; and (3) monthly. Hand hygiene rates among health care workers were documented at entry and exit to patient rooms during the baseline period from October 1, 2014, to March 31, 2015, of normal signage and throughout the intervention period of June 8, 2015, to December 28, 2015. Data analyses were conducted in April 2018. Interventions: Hospital units were randomly assigned into 3 groups: (1) no sign changes throughout the intervention period, (2) signs changed weekly, and (3) signs changed monthly. Main Outcomes and Measures: Hand hygiene adherence as measured by covert observation. Interrupted time series analysis was used to examine changes in HH adherence from baseline through the intervention period by group. Results: Among 58 inpatient units, 19 units were assigned to the no change group, 19 units were assigned to the weekly change group, and 20 units were assigned to the monthly change group. During the baseline period, 9755 HH opportunities were observed at room entry and 10 095 HH opportunities were observed at room exit. During the intervention period, a total of 15 855 HH opportunities were observed at room entry, and 16 360 HH opportunities were observed at room exit. Overall HH adherence did not change from baseline compared with the intervention period at either room entry (4770 HH events [48.9%] vs 3057 HH events [50.1%]; P = .14) or exit (6439 HH events [63.8%] vs 4087 HH events [65.2%]; P = .06). In units that changed signs weekly, HH adherence declined from baseline at room entry (-1.9% [95% CI, -2.7% to -0.8%] per week; P < .001) and exit (-0.8% [95% CI, -1.5% to 0.1%] per week; P = .02). No significant changes in HH adherence were observed in other groups. Conclusions and Relevance: The frequency of changing reminder signs had no effect on HH rates overall. Units assigned to change signs most frequently demonstrated worsening adherence. Considering the abundance of signs in the acute care environment, the frequency of changing signs did not appear to provide a strong enough cue by itself to promote behavioral change. Trial Registration: ClinicalTrials.gov Identifier: NCT02223455.

Testing a novel audit and feedback method for hand hygiene compliance: A multicenter quality improvement study.

OBJECTIVE: Although most hospitals report very high levels of hand hygiene compliance (HHC), the accuracy of these overtly observed rates is questionable due to the Hawthorne effect and other sources of bias. In the study, we aimed (1) to compare HHC rates estimated using the standard audit method of overt observation by a known observer and a new audit method that employed a rapid (<15 minutes) "secret shopper" method and (2) to pilot test a novel feedback tool. DESIGN: Quality improvement project using a quasi-experimental stepped-wedge design. SETTING: This study was conducted in 5 acute-care hospitals (17 wards, 5 intensive care units) in the Midwestern United States. METHODS: Sites recruited a hand hygiene observer from outside the acute-care units to rapidly and covertly observe entry and exit HHC during the study period, October 2016-September 2017. After 3 months of observations, sites received a monthly feedback tool that communicated HHC information from the new audit method. RESULTS: The absolute difference in HHC estimates between the standard and new audit methods was ~30%. No significant differences in HHC were detected between the baseline and feedback phases (OR, 0.92; 95% CI, 0.84-1.01), but the standard audit method had significantly higher estimates than the new audit method (OR, 9.83; 95% CI, 8.82-10.95). CONCLUSIONS: HHC estimates obtained using the new audit method were substantially lower than estimates obtained using the standard audit method, suggesting that the rapid, secret-shopper method is less subject to bias. Providing feedback using HHC from the new audit method did not seem to impact HHC behaviors.

Evaluation of Barriers to Audit-and-Feedback Programs That Used Direct Observation of Hand Hygiene Compliance: A Qualitative Study.

Importance: Audit and feedback based on direct observation is a common strategy to improve hand hygiene compliance, but the optimal design and delivery of this intervention are poorly defined. Objective: To describe barriers encountered by audit-and-feedback programs for hand hygiene across acute care hospitals within the Veterans Health Administration. Design, Setting, and Participants: A qualitative study was conducted at a geographically diverse convenience sample of 10 acute care hospitals within the Veterans Health Administration. Participants included 108 infection prevention team personnel and frontline staff. All data were collected between June 30, 2014, and March 18, 2015. Data were analyzed between September 6, 2017, and January 5, 2018. Main Outcomes and Measures: Barriers to audit and feedback for hand hygiene compliance were evaluated. Semistructured interviews of key personnel were performed through site visits at 6 locations and telephone interviews with 4 sites. Focus groups were conducted with frontline staff. Interviews and focus groups were audio recorded and transcribed. All transcripts were analyzed using thematic content analysis. Results: Overall, 108 individuals participated in the study. Semistructured interviews were conducted with 38 individuals, who were predominantly infection prevention team members. Focus group interviews were conducted with 70 frontline hospital staff members. Surveillance activities at all 10 sites made use of a variety of staff members with the intention of covertly collecting direct observations on hand hygiene compliance. Monitoring programs were challenging to maintain because of constraints on time and personnel. Both auditors and frontline staff expressed skepticism about the accuracy of compliance data based on direct observations. Auditors expressed concern about the Hawthorne effect, while frontline staff were worried that their compliance was not visible to auditors. In most hospitals, approaches to monitoring hand hygiene compliance produced friction between frontline staff and infection prevention teams. The feedback process for audit results did not consistently reach frontline staff and, in many hospitals, did not seem to facilitate improvement efforts. Conclusions and Relevance: Auditing hand hygiene compliance with direct observation was problematic across these acute care hospitals. Auditing was perceived to collect inaccurate data and created tension with frontline staff, and the feedback process did not appear to encourage positive change. Strategies are needed to collect more reliable hand hygiene data and facilitate multidisciplinary collaboration toward improved compliance.

Bedside Critical Care Staff Use of Intensive Care Unit Telemedicine: Comparisons by Intensive Care Unit Complexity.

BACKGROUND: Effects of Intensive Care Unit (ICU) telemedicine on patient and staff outcomes are mixed. Variation in utilization is potentially driving these differences. INTRODUCTION: ICU telemedicine utilization is understudied, with existing research focusing on telemedicine staff. We assess ICU telemedicine utilization from the perspective of the end user-ICU staff-to better understand how telemedicine use is conceptualized and practiced at the bedside. MATERIALS AND METHODS: We conducted a thematic content analysis of semistructured interviews with bedside ICU staff. Staff were interviewed at seven ICUs in six Veterans Health Administration facilities, representing varying ICU complexities and points in time (2 and 12 months postimplementation of ICU telemedicine). RESULTS: Fifty-eight bedside ICU staff described instances of telemedicine use, which were categorized into three types: Urgent ICU Patient Care, Clinical Decision-Making and Support, and General ICU Patient Care. The most commonly described use was General ICU Patient Care and the least common was Urgent ICU Patient Care. ICU staff from lower complexity ICUs had fewer descriptions of use compared to staff at higher complexity ICUs. At 12 months postimplementation, staff recounted more instances of all three utilization types. DISCUSSION: It is important to understand how telemedicine is being used within ICUs to evaluate its impact. The presence of three types of use, variability in use by ICU complexity, and change in use over time suggest the need for comprehensive measures of utilization to evaluate effectiveness. CONCLUSIONS: ICU telemedicine needs to develop an agreed upon typology for documenting ICU telemedicine utilization and incorporate these measures into models of its effect on clinical outcomes.

Introduction of Tele-ICU in rural hospitals: Changing organisational culture to harness benefits.

OBJECTIVE: This study evaluates rural hospital staff perceptions of a telemedicine ICU (Tele-ICU) before and after implementation. METHODS: We conducted a longitudinal qualitative study utilising semistructured group or individual interviews with staff from three rural ICU facilities in the upper Midwest of the United States that received Tele-ICU support. Interviews occurred pre-implementation and at two time points post-implementation. Interviews were conducted with: ICU administrators (n=6), physicians (n=3), nurses (n=9), respiratory therapists (n=5) and other (n=1) from July 2011 to May 2013. Transcripts were analysed for thematic content. FINDINGS: Overall, rural ICU staff viewed Tele-ICU as a welcome benefit for their facility. Major themes included: (1) beneficial where recruitment and retention of staff can be challenging; (2) extra support for day shifts and evening, night and weekend shifts; (3) reduction in the number of transfers larger tertiary hospitals in the community; (4) improvement in standardisation of care; and (5) organisational culture of rural ICUs may lead to under-utilisation. CONCLUSIONS: ICU staff at rural facilities view Tele-ICU as a positive, useful tool to provide extra support and assistance. However, more research is needed regarding organisational culture to maximise the potential benefits of Tele-ICU in rural hospitals.