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.

RE-AIM for rural health innovations: perceptions of (mis) alignment between the RE-AIM framework and evaluation reporting in the Department of Veterans Affairs Enterprise-Wide Initiatives program.

Background: The Department of Veterans Affairs (VA) Office of Rural Health (ORH) supports national VA program offices' efforts to expand health care to rural Veterans through its Enterprise-Wide Initiatives (EWIs) program. In 2017, ORH selected Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM), an implementation science framework, to structure the EWI evaluation and reporting process. As part of its mandate to improve EWI program evaluation, the Center for the Evaluation of Enterprise-Wide Initiatives conducted a qualitative evaluation to better understand EWI team' perceptions of, and barriers and facilitators to, the EWI evaluation process. Methods: We conducted 43 semi-structured interviews with 48 team members (e.g., evaluators, program office leads, and field-based leads) representing 21 EWIs from April-December 2020. Questions focused on participants' experiences using strategies targeting each RE-AIM dimension. Interviews were inductively analyzed in MAXQDA. We also systematically reviewed 51 FY19-FY20 EWI annual reports to identify trends in misapplications of RE-AIM. Results: Participants had differing levels of experience with RE-AIM. While participants understood ORH's rationale for selecting a common framework to structure evaluations, the perceived misalignment between RE-AIM and EWIs' work emerged as an important theme. Concerns centered around 3 sub-themes: (1) (Mis)Alignment with RE-AIM Dimensions, (2) (Mis)Alignment between RE-AIM and the EWI, and (3) (Mis)Alignment with RE-AIM vs. other Theories, Models, or Frameworks. Participants described challenges differentiating between and operationalizing dimensions in unique contexts. Participants also had misconceptions about RE-AIM and its relevance to their work, e.g., that it was meant for established programs and did not capture aspects of initiative planning, adaptations, or sustainability. Less commonly, participants shared alternative models or frameworks to RE-AIM. Despite criticisms, many participants found RE-AIM useful, cited training as important to understanding its application, and identified additional training as a future need. Discussion: The selection of a shared implementation science framework can be beneficial, but also challenging when applied to diverse initiatives or contexts. Our findings suggest that establishing a common understanding, operationalizing framework dimensions for specific programs, and assessing training needs may better equip partners to integrate a shared framework into their evaluations.

Using a human-factors engineering approach to evaluate environmental cleaning in Veterans' Affairs acute and long-term care facilities: A qualitative analysis.

BACKGROUND: Environmental cleaning is important in the interruption of pathogen transmission. Although prevention initiatives have targeted environmental cleaning, practice variations exist and compliance is low. Evaluation of human factors influencing variations in cleaning practices can be valuable in developing interventions to standardized practices. We conducted a work-system analysis using a human-factors engineering (HFE) framework to identify barriers and facilitators to environmental cleaning practices in acute and long-term care settings within the Veterans' Affairs health system. METHODS: We conducted a qualitative study with key stakeholders at 3 VA facilities. We analyzed transcripts for thematic content and mapped themes to the HFE framework. RESULTS: Staffing consistency was felt to improve cleaning practices and teamwork. We found that many environmental management service (EMS) staff were veterans who were motivated to serve fellow veterans, especially to prevent infections. However, hiring veterans comes with regulatory hurdles that affect staffing. Sites reported some form of monitoring their cleaning process, but there was variation in method and frequency. The EMS workload was affected by whether rooms were occupied by patients or were semiprivate rooms; both were reportedly more difficult to clean. Room design and surface finishes were identified as important to cleaning efficiency. CONCLUSION: HFE work analysis identified barriers and facilitators to environmental cleaning. These findings highlight intervention entry points that may facilitate standardized work practices. There is a need to develop task-specific procedures such as cleaning occupied beds and semiprivate rooms. Future research should evaluate interventions that address these determinants of environmental cleaning.

Effectiveness of Ultraviolet-C Disinfection on Hospital-Onset Gram-Negative Rod Bloodstream Infection: A Nationwide Stepped-Wedge Time-Series Analysis.

BACKGROUND: The effectiveness of enhanced terminal room cleaning with ultraviolet C (UV-C) disinfection in reducing gram-negative rod (GNR) infections has not been well evaluated. We assessed the association of implementation of UV-C disinfection systems with incidence rates of hospital-onset (HO) GNR bloodstream infection (BSI). METHODS: We obtained information regarding UV-C use and the timing of implementation through a survey of all Veterans Health Administration (VHA) hospitals providing inpatient acute care. Episodes of HO-GNR BSI were identified between January 2010 and December 2018. Bed days of care (BDOC) was used as the denominator. Over-dispersed Poisson regression models were fitted with hospital-specific random intercept, UV-C disinfection use for each month, baseline trend, and seasonality as explanatory variables. Hospitals without UV-C use were also included to the analysis as a nonequivalent concurrent control group. RESULTS: Among 128 VHA hospitals, 120 provided complete survey responses with 40 reporting implementations of UV-C systems. We identified 13 383 episodes of HO-GNR BSI and 24 141 378 BDOC. UV-C use was associated with a lower incidence rate of HO-GNR BSI (incidence rate ratio: 0.813; 95% confidence interval: .656-.969; P = .009). There was wide variability in the effect size of UV-C disinfection use among hospitals. CONCLUSIONS: In this large quasi-experimental analysis within the VHA System, enhanced terminal room cleaning with UV-C disinfection was associated with an approximately 19% lower incidence of HO-GNR BSI, with wide variability in effectiveness among hospitals. Further studies are needed to identify the optimal implementation strategy to maximize the effectiveness of UV-C disinfection technology.

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.

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.

The feasibility of implementing antibiotic restrictions for fluoroquinolones and cephalosporins: a mixed-methods study across 15 Veterans Health Administration hospitals.

INTRODUCTION: The optimal method for implementing hospital-level restrictions for antibiotics that carry a high risk of Clostridioides difficile infection has not been identified. We aimed to explore barriers and facilitators to implementing restrictions for fluoroquinolones and third/fourth-generation cephalosporins. METHODS: This mixed-methods study across a purposeful sample of 15 acute-care, geographically dispersed Veterans Health Administration hospitals included electronic surveys and semi-structured interviews (September 2018 to May 2019). Surveys on stewardship strategies were administered at each hospital and summarized with descriptive statistics. Interviews were performed with 30 antibiotic stewardship programme (ASP) champions across all 15 sites and 19 additional stakeholders at a subset of 5 sites; transcripts were analysed using thematic content analysis. RESULTS: The most restricted agent was moxifloxacin, which was restricted at 12 (80%) sites. None of the 15 hospitals restricted ceftriaxone. Interviews identified differing opinions on the feasibility of restricting third/fourth-generation cephalosporins and fluoroquinolones. Some participants felt that restrictions could be implemented in a way that was not burdensome to clinicians and did not interfere with timely antibiotic administration. Others expressed concerns about restricting these agents, particularly through prior approval, given their frequent use, the difficulty of enforcing restrictions and potential unintended consequences of steering clinicians towards non-restricted antibiotics. A variety of stewardship strategies were perceived to be effective at reducing the use of these agents. CONCLUSIONS: Across 15 hospitals, there were differing opinions on the feasibility of implementing antibiotic restrictions for third/fourth-generation cephalosporins and fluoroquinolones. While the perceived barrier to implementing restrictions was frequently high, many hospitals were effectively using restrictions and reported few barriers to their use.

Development of a fully automated surgical site infection detection algorithm for use in cardiac and orthopedic surgery research.

OBJECTIVE: To develop a fully automated algorithm using data from the Veterans' Affairs (VA) electrical medical record (EMR) to identify deep-incisional surgical site infections (SSIs) after cardiac surgeries and total joint arthroplasties (TJAs) to be used for research studies. DESIGN: Retrospective cohort study. SETTING: This study was conducted in 11 VA hospitals. PARTICIPANTS: Patients who underwent coronary artery bypass grafting or valve replacement between January 1, 2010, and March 31, 2018 (cardiac cohort) and patients who underwent total hip arthroplasty or total knee arthroplasty between January 1, 2007, and March 31, 2018 (TJA cohort). METHODS: Relevant clinical information and administrative code data were extracted from the EMR. The outcomes of interest were mediastinitis, endocarditis, or deep-incisional or organ-space SSI within 30 days after surgery. Multiple logistic regression analysis with a repeated regular bootstrap procedure was used to select variables and to assign points in the models. Sensitivities, specificities, positive predictive values (PPVs) and negative predictive values were calculated with comparison to outcomes collected by the Veterans' Affairs Surgical Quality Improvement Program (VASQIP). RESULTS: Overall, 49 (0.5%) of the 13,341 cardiac surgeries were classified as mediastinitis or endocarditis, and 83 (0.6%) of the 12,992 TJAs were classified as deep-incisional or organ-space SSIs. With at least 60% sensitivity, the PPVs of the SSI detection algorithms after cardiac surgeries and TJAs were 52.5% and 62.0%, respectively. CONCLUSIONS: Considering the low prevalence rate of SSIs, our algorithms were successful in identifying a majority of patients with a true SSI while simultaneously reducing false-positive cases. As a next step, validation of these algorithms in different hospital systems with EMR will be needed.

Antibiotic use during end-of-life care: A systematic literature review and meta-analysis.

BACKGROUND: We performed a systematic literature review and meta-analysis measuring the burden of antibiotic use during end-of-life (EOL) care. METHODS: We searched PubMed, CINAHL (EBSCO platform), and Embase (Elsevier platform), through July 2019 for studies with the following inclusion criteria in the initial analysis: antibiotic use in the EOL care patients (advanced dementia, cancer, organ failure, frailty or multi-morbidity). If the number of patients in palliative care consultation (PCC) was available, antibiotic use data were pooled to compare the proportion of patients who received antibiotics under PCC compared to those not receiving PCC. Random-effect models were used to obtain pooled mean differences, and heterogeneity was assessed using the I2 value. RESULTS: Overall, 72 studies met the inclusion criteria and were included in the final review: 22 EOL studies included only patients with cancer; 17 studies included only patients with advanced dementia; and 33 studies included "mixed populations" of EOL patients. Although few studies reported antibiotic using standard metrics (eg, days of therapy), 48 of 72 studies (66.7%) reported antibiotic use in >50% of all patients. When the 3 studies that evaluated antibiotic use in PCC were pooled together, patients under PCC was more likely to receive antibiotics compared to patients not under PCC (pooled odds ratio, 1.73; 95% CI, 1.02-2.93). CONCLUSIONS: Future studies are needed to evaluate the benefits and harms of using antibiotics for patients during EOL care in diverse patient populations.

Incidence and Outcomes Associated With Clostridium difficile Infections: A Systematic Review and Meta-analysis.

Importance: An understanding of the incidence and outcomes of Clostridium difficile infection (CDI) in the United States can inform investments in prevention and treatment interventions. Objective: To quantify the incidence of CDI and its associated hospital length of stay (LOS) in the United States using a systematic literature review and meta-analysis. Data Sources: MEDLINE via Ovid, Cochrane Library Databases via Wiley, Cumulative Index of Nursing and Allied Health Complete via EBSCO Information Services, Scopus, and Web of Science were searched for studies published in the United States between 2000 and 2019 that evaluated CDI and its associated LOS. Study Selection: Incidence data were collected only from multicenter studies that had at least 5 sites. The LOS studies were included only if they assessed postinfection LOS or used methods accounting for time to infection using a multistate model or compared propensity score-matched patients with CDI with control patients without CDI. Long-term-care facility studies were excluded. Of the 119 full-text articles, 86 studies (72.3%) met the selection criteria. Data Extraction and Synthesis: Two independent reviewers performed the data abstraction and quality assessment. Incidence data were pooled only when the denominators used the same units (eg, patient-days). These data were pooled by summing the number of hospital-onset CDI incident cases and the denominators across studies. Random-effects models were used to obtain pooled mean differences. Heterogeneity was assessed using the I2 value. Data analysis was performed in February 2019. Main Outcomes and Measures: Incidence of CDI and CDI-associated hospital LOS in the United States. Results: When the 13 studies that evaluated incidence data in patient-days due to hospital-onset CDI were pooled, the CDI incidence rate was 8.3 cases per 10 000 patient-days. Among propensity score-matched studies (16 of 20 studies), the CDI-associated mean difference in LOS (in days) between patients with and without CDI varied from 3.0 days (95% CI, 1.44-4.63 days) to 21.6 days (95% CI, 19.29-23.90 days). Conclusions and Relevance: Pooled estimates from currently available literature suggest that CDI is associated with a large burden on the health care system. However, these estimates should be interpreted with caution because higher-quality studies should be completed to guide future evaluations of CDI prevention and treatment interventions.

A systematic review of the epidemiology of carbapenem-resistant Enterobacteriaceae in the United States.

Background: Carbapenem-resistant Enterobacteriaceae (CRE) pose an urgent public health threat in the United States. An important step in planning and monitoring a national response to CRE is understanding its epidemiology and associated outcomes. We conducted a systematic literature review of studies that investigated incidence and outcomes of CRE infection in the US. Methods: We performed searches in MEDLINE via Ovid, CDSR, DARE, CENTRAL, NHS EED, Scopus, and Web of Science for articles published from 1/1/2000 to 2/1/2016 about the incidence and outcomes of CRE at US sites. Results: Five studies evaluated incidence, but many used differing definitions for cases. Across the entire US population, the reported incidence of CRE was 0.3-2.93 infections per 100,000 person-years. Infection rates were highest in long-term acute-care (LTAC) hospitals. There was insufficient data to assess trends in infection rates over time. Four studies evaluated outcomes. Mortality was higher in CRE patients in some but not all studies. Conclusion: While the incidence of CRE infections in the United States remains low on a national level, the incidence is highest in LTACs. Studies assessing outcomes in CRE-infected patients are limited in number, small in size, and have reached conflicting results. Future research should measure a variety of clinical outcomes and adequately adjust for confounders to better assess the full burden of CRE.