Evaluating remote facilitation intensity for multi-national translation of nurse-initiated stroke protocols (QASC Australasia): a protocol for a cluster randomised controlled trial.

BACKGROUND: Facilitated implementation of nurse-initiated protocols to manage fever, hyperglycaemia (sugar) and swallowing difficulties (FeSS Protocols) in 19 Australian stroke units resulted in reduced death and dependency for stroke patients. However, a significant gap remains in translating this evidence-based care bundle protocol into standard practice in Australia and New Zealand. Facilitation is a key component for increasing implementation. However, its contribution to evidence translation initiatives requires further investigation. We aim to evaluate two levels of intensity of external remote facilitation as part of a multifaceted intervention to improve FeSS Protocol uptake and quality of care for patients with stroke in Australian and New Zealand acute care hospitals. METHODS: A three-arm cluster randomised controlled trial with a process evaluation and economic evaluation. Australian and New Zealand hospitals with a stroke unit or service will be recruited and randomised in blocks of five to one of the three study arms-high- or low-intensity external remote facilitation or a no facilitation control group-in a 2:2:1 ratio. The multicomponent implementation strategy will incorporate implementation science frameworks (Theoretical Domains Framework, Capability, Opportunity, Motivation - Behaviour Model and the Consolidated Framework for Implementation Research) and include an online education package, audit and feedback reports, local clinical champions, barrier and enabler assessments, action plans, reminders and external remote facilitation. The primary outcome is implementation effectiveness using a composite measure comprising six monitoring and treatment elements of the FeSS Protocols. Secondary outcome measures are as follows: composite outcome of adherence to each of the combined monitoring and treatment elements for (i) fever (n=5); (ii) hyperglycaemia (n=6); and (iii) swallowing protocols (n=7); adherence to the individual elements that make up each of these protocols; comparison for composite outcomes between (i) metropolitan and rural/remote hospitals; and (ii) stroke units and stroke services. A process evaluation will examine contextual factors influencing intervention uptake. An economic evaluation will describe cost differences relative to each intervention and study outcomes. DISCUSSION: We will generate new evidence on the most effective facilitation intensity to support implementation of nurse-initiated stroke protocols nationwide, reducing geographical barriers for those in rural and remote areas. TRIAL REGISTRATION: ACTRN12622000028707. Registered 14 January, 2022.

Barriers and enablers to implementinghospital-acquired urinary tract infection prevention strategies: a qualitative study using the Theoretical Domains Framework.

BACKGROUND: Consistent implementation of evidence-based hospital-acquired urinary tract infection (UTI) prevention strategies remains a challenge in acute and subacute care settings. Addressing the evidence-practice gap requires an understanding of factors affecting implementation of hospital-acquired UTI prevention strategies in this high-risk setting. AIM: To identify the perceived barriers and enablers of clinicians to implementing hospital-acquired UTI prevention strategies in an Australian subacute hospital. METHODS: Qualitative semi-structured virtual interviews, underpinned by the Theoretical Domains Framework (TDF), were conducted with purposively selected nurses (N = 8) and doctors (N = 2) at one subacute metropolitan hospital. Interview data were content-analysed using the TDF as the coding framework. FINDINGS: Eight TDF domains were identified as important in understanding barriers and enablers to implementing hospital-acquired UTI prevention strategies: Knowledge, Skills, Beliefs about capabilities, Emotion, Professional role and identity, Environmental context and resources, Goals, and Behavioural regulation. Barriers were poor awareness of clinical practice guidelines for hospital-acquired UTI prevention; lack of training; staff shortages; competing workloads; lack of procedural equipment for urinary catheterization; difficulty with implementing prevention strategies in cognitively impaired patients; language barriers; and lack of feedback and use of incident reporting data to influence clinical practice. Presence of a proactive staff culture and positive team approach to work emerged as enablers. Audit and feedback, clinical champions, education, and patient information resources in languages other than English were identified as potential enablers. CONCLUSION: The findings will inform development of theoretically informed behaviour change interventions to promote successful implementation of hospital-acquired UTI prevention strategies in the subacute setting.

Where is the strength of evidence? A review of infection prevention and control guidelines.

An important aspect of safety and quality in healthcare is the implementation of infection prevention and control guidelines. However, little is known regarding the strength of evidence on which recommendations for such guidelines are based. This study aimed to describe the strength of recommendations of infection prevention and control guidelines published in the last 10 years. For this review, the websites of government and professional organizations for national and international infection prevention and control clinical guidelines were purposively searched. The search was limited to publications between January 2009 and April 2019, and those with a formal grading system were used to determine the strength of the evidence underpinning the recommendations. Recommendations from guidelines were categorized into 21 infection control categories. A descriptive synthesis of the data was undertaken. A total of 31 guidelines comprising 1855 recommendations were included. Guidelines were mainly developed in the USA (N = 11, 35.5%) and Canada (N = 9, 29.0%). Most guidelines used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach (N = 6, 19.4%. The majority of the guidelines contained recommendations categorized under the themes of devices (N = 316, 16.9%) and transmission-based precautions (N = 315, 16.8%). Most recommendations (N = 769, 41.5%) were graded as using evidence from descriptive studies, expert opinion and low-quality evidence. There are a vast number of infection prevention and control guidelines developed by national and international government or professional organizations, many without a strong evidence base. This presents multiple research opportunities that should prioritize common prevention activities that currently have a low evidence base.

Increased fluid intake for the prevention of urinary tract infection in adults and children in all settings: a systematic review.

BACKGROUND: Non-antibiotic interventions for urinary tract infection (UTI) prevention have been investigated as a strategy to reduce antibiotic prescribing for UTI and subsequent antibiotic resistance. Increased hydration is widely advocated for preventing UTI; however, evidence for its effectiveness is unknown. AIM: To systematically review the published literature on the effectiveness of increased fluid intake as a preventive intervention for UTI in adults and children in any setting. METHODS: Five electronic databases were searched from inception to February 2019 to identify published randomized controlled trials (RCTs) and quasi-experimental studies evaluating the effectiveness of high (≥1.5 L/24 h) versus normal/low (<1.5 L/24 h) fluid intake for UTI prevention. The outcome was UTI incidence. Risk of bias was assessed using the Cochrane Collaboration's tool. Due to the small number of studies identified, meta-analysis was not possible. Hence a narrative synthesis was undertaken. FINDINGS: Of the 2822 potentially relevant papers, two were eligible for inclusion: an RCT (individual randomization) and a cluster-RCT. Both studies differed regarding participants, setting, sample size, UTI definition, and intervention. The RCT was assessed as having a low risk of bias whereas the cluster-RCT had a high risk of bias. Only the RCT, which included healthy premenopausal women visiting primary care clinics, demonstrated statistical significance for the effect of high fluid intake for UTI prevention. CONCLUSION: The lack of enough adequately powered and robust RCTs highlights the need for further research on the effectiveness of this intervention for UTI prevention.

Development and evaluation of a website for surveillance of healthcare-associated urinary tract infections in Australia.

Phase II of the Surveillance to Reduce Urinary Tract Infections project piloted a website for point prevalence surveys of healthcare-associated (HAUTI) and catheter-associated urinary tract infection in Australian hospitals and aged care homes. This report describes development and evaluation of the website for online data collection. Evaluation findings from 38 data collectors indicated that most respondents found website registration and web form use easy (N = 22; 58% and N = 16; 43%, respectively). The need for improved computer literacy skills and automated data systems were highlighted. This study demonstrated a novel approach for Australian HAUTI data collection; however, refinements are needed before national roll-out.

Systematic review and meta-analysis of the effectiveness of antiseptic agents for meatal cleaning in the prevention of catheter-associated urinary tract infections.

BACKGROUND: Catheter-associated urinary tract infections (CAUTIs) are among the most common healthcare-associated infections. Antiseptic cleaning of the meatal area before and during catheter use may reduce the risk of CAUTIs. AIM: To undertake a systematic review of the literature and meta-analysis of studies investigating the effectiveness of antiseptic cleaning before urinary catheter insertion and during catheter use for prevention of CAUTIs. METHODS: Electronic databases were searched to identify randomized controlled trials. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated and compared across intervention and control groups using DerSimonian-Laird random-effects model. Subgroup analyses were performed. Heterogeneity was estimated using the I2 statistic. FINDINGS: In total, 2665 potential papers were identified; of these, 14 studies were eligible for inclusion. There was no difference in the incidence of CAUTIs when comparing antiseptic and non-antiseptic agents (pooled OR 0.90, 95% CI 0.73-1.10; P=0.31), or when comparing different agents: povidone-iodine vs routine care; povidone-iodine vs soap and water; chlorhexidine vs water; povidone-iodine vs saline; povidone-iodine vs water; and green soap and water vs routine care (P>0.05 for all). Comparison of an antibacterial agent with routine care indicated near significance (P=0.06). There was no evidence of heterogeneity (I2=0%; P>0.05). Subgroup analyses showed no difference in the incidence of CAUTIs in terms of country, setting, risk of bias, sex and frequency of administration. CONCLUSIONS: There were no differences in CAUTI rates, although methodological issues hamper generalizability of this finding. Antibacterial agents may prove to be significant in a well-conducted study. The present results provide good evidence to inform infection control guidelines in catheter management.