ABSTRACT
Background. Timely diagnosis and use of contact precautions for Clostridioides difficile infection (CDI) is key to prevent spread in hospital settings. Empowering nursing staff to order stool tests and proactively implement precautions has been shown to reduce hospital acquired CDI. Our institution established a nurse driven CDI order set in 2019, however only 1% of tests were ordered by nurses in the past year. The goal of this quality improvement project was to understand current use of the nurse-driven CDI order set using a novel humble inquiry approach. Methods. We used humble inquiry, an interview approach that poses questions while building relationships with participants through humility, curiosity, and active listening skills to explore barriers to utilization of a nurse driven CDI order set. Two nursing students at a 182-bed Veterans Health Administration (VA) hospital were trained to use humble inquiry and a three-item interview guide. A convenience sample of nurses and nursing assistants were interviewed about a) what they know about the nurse driven CDI order set, b) where there is documentation about the order set and c) barriers to use of the order set (if any). Interviews were conducted from January to April 2022. Demographics were analyzed descriptively. Interview data and the experience of conducting humble inquiry were analyzed using manifest content analysis. Results. Interviews (n=19) with nurses (n=16) and nursing assistants (n=3) revealed the majority (13/19 = 68%) were not aware of the nurse driven CDI order set. Of those aware, most were able to identify the location of information on their unit and where to document in the electronic medical record. The two most common barriers included lack of awareness of the order set and patient reluctance to disclose their bowel habits. Delay in providers reading notes (3/19=16%) and lack of PPE during COVID (1/19= 5%) were also identified as barriers. The nursing students reported the humble inquiry approach allowed participants to be the "experts" and "teachers". Conclusion. The humble inquiry method was valuable in understanding viewpoints and identifying barriers to utilization of a nurse drive CDI order set. Lack of awareness of the order set and patient modesty were identified as barriers and may be targeted for future interventions.
ABSTRACT
BackgroundThe uptake of face-to-face supervised outpatient-based pulmonary rehabilitation (PR) following hospitalisation for an acute exacerbation of COPD (AECOPD) is low. One commonly cited barrier is travel. Home-based PR may be an alternative setting. The aim of this study was to determine whether a co-designed home-based exercise training intervention, delivered alongside usual hospital at home (HaH) care post-hospitalisation for an AECOPD, is acceptable and feasible.MethodsA mixed method feasibility study was conducted including a parallel, two-group randomised controlled trial (RCT) (control group: usual HaH care;intervention group: usual care plus home-based exercise training) with convergent qualitative components (interviews: patients, family carers, researchers;focus groups: healthcare professionals [HCPs]).Results16/132 patients screened were recruited to the RCT with 8 allocated to each group and one withdrawn prior to receiving HaH care (56% were male, mean [SD] age: 74 [9] years, median [IQR] FEV1: 29 [21, 40] percent predicted, 87% with an eMRC dyspnoea score of 4, 5a or 5b). Four vs eight and four vs seven attended four week and three-month follow-up assessments in the control and intervention groups respectively. There was no evidence of contamination in the control group. 25% of patients allocated to the intervention group were unable to receive the intervention due to Covid-19. The questionnaire-based outcomes were more complete and appeared more acceptable to patients than physical measures, with very poor uptake for physical activity monitoring via accelerometery. Qualitative findings (interviews: five patients, two family carers, four researchers;focus groups: PR and HaH service HCPs) demonstrated that trial and intervention processes were acceptable, clinically beneficial and safe, but did not explain the disparity between questionnaire-based vs physical outcome measure completion rates.ConclusionThe findings suggest an efficacy trial which investigates home-based exercise training integrated within a HaH service following hospitalisation for an AECOPD would be safe and acceptable to patients, family carers, HCPs and researchers alike, and is qualitatively felt to be of clinical benefit. However, additional piloting is required to optimise intervention fidelity and study processes given the low recruitment rates, high drop out of the control group and poor uptake of some physical assessments.