scholarly journals 1101. What Do Electrophysiologists Think about Peri-Procedural Antibiotics? A Qualitative Assessment of Factors Driving Use and Facilitators for Implementing Change

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S391-S391
Author(s):  
Westyn Branch-Elliman ◽  
Rani Elwy ◽  
Kalpana Gupta
Keyword(s):  
Antimicrobial Prophylaxis ◽  
Qualitative Interviews ◽  
Academic Community ◽  
Qualitative Assessment ◽  
Local Culture ◽  
Successful Implementation ◽  
Antimicrobial Use ◽  
Cardiac Device ◽  
Implementing Change ◽  
Formative Evaluations

Abstract Background Prolonged courses of antimicrobials are common following cardiac device procedures, but there are little data to explain drivers of this practice and factors that may facilitate change. Methods We conducted formative evaluations consisting of semi-structured, qualitative interviews with electrophysiologists (EP) to identify perceived barriers to discontinuing post-procedure antimicrobial prophylaxis and factors that may facilitate improvements. A directed content analysis approach was used to map qualitative responses to key factors in the Proctor Implementation Outcomes Framework, with flexibility to allow for new themes to emerge. Interviews ceased after data saturation was reached. Results 13 interviews were conducted with EPs representing diverse US regions (Northeast, Midwest, South, West) and diverse settings of care (academic, community, VA). Responses to questions about antimicrobial use and willingness (or lack thereof) to stop post-procedural antimicrobials most commonly mapped to the acceptability domain; feasibility, fidelity, cost and appropriateness were also frequently identified factors (see figure for exemplary quotes). Themes that emerged during the interview process associated with prolonged antimicrobial prescribing included beliefs and knowledge, local culture and normative behaviors, and organizational structure. There was a strong “cultural inertia” to conform to normative practices within an institution. Reasons for this ranged from reports of streamlining processes for clinical staff to ensure standardized care across all patients and concerns about being perceived as an “outlier.” Infectious diseases staff were important influencers of practice and potential facilitators of improvement. Conclusion Formative evaluations of stakeholders are essential for designing successful implementation interventions to facilitate behavioral change. Local culture appeared to be a major driver of antimicrobial use. The desire to conform to normative behaviors and to promote institutional standardization suggests that strategies to facilitate implementation of antimicrobial stewardship guidelines must include facility-level changes, rather than individual-provider-level interventions. Disclosures All authors: No reported disclosures.

scholarly journals Promoting De-Implementation of Inappropriate Antimicrobial Use in Cardiac Device Procedures By Expanding Audit and Feedback: Protocol for Hybrid III Type Effectiveness/ Implementation Quasi-Experimental Study

2021 ◽  
Author(s):  
Westyn Branch-Elliman ◽  
Rebecca Lamkin ◽  
Marlena Shin ◽  
Hillary J Mull ◽  
Isabella Epshtein ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Qualitative Interviews ◽  
Inappropriate Prescribing ◽  
Audit And Feedback ◽  
Primary Study ◽  
Antimicrobial Use ◽  
Provider Education ◽  
Implementation Barriers ◽  
Cardiac Device ◽  
Formative Evaluations

Abstract Background: Despite a strong evidence base and clinical guidelines specifically recommending against prolonged post-procedural antimicrobial use, studies indicate that the practice is common following cardiac device procedures. Formative evaluations conducted by the study team suggest that inappropriate antimicrobial use may be driven by information silos that drive provider belief that antimicrobials are not harmful, in part due to lack of complete feedback about all types of clinical outcomes. De-implementation is recognized as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excess antimicrobial use following cardiac device procedures; however, investigations into strategies that lead to successful de-implementation are limited. The overarching hypothesis to be tested in this trial is that a bundle of implementation strategies that includes audit and feedback about direct patient harms caused by inappropriate prescribing can lead to successful de-implementation of guideline-discordant care.Methods: We propose a Hybrid Type III effectiveness-implementation stepped-wedge intervention trial at three high-volume, high-complexity VA medical centers. The main study intervention (an informatics-based, real-time audit-and-feedback tool) was developed based on learning/unlearning theory and formative evaluations and guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) Framework. Elements of the bundled and multifaceted implementation strategy to promote appropriate prescribing will include audit-and-feedback reports that include information about antibiotic harms, stakeholder engagement, patient and provider education, identification of local champions, and blended facilitation. The primary study outcome is adoption of evidence-based practice (de-implementation of inappropriate antimicrobial use). Clinical outcomes (cardiac device infections, acute kidney injuries and Clostridioides difficile infections) are secondary. Qualitative interviews will assess relevant implementation outcomes (acceptability, adoption, fidelity, feasibility).Discussion: De-implementation theory suggests that factors that may have a particularly strong influence on de-implementation include strength of the underlying evidence, the complexity of the intervention, and patient and provider anxiety and fear about changing an established practice. This study will assess whether a multifaceted intervention mapped to identified de-implementation barriers leads to measurable improvements in provision of guideline-concordant antimicrobial use. Findings will improve understanding about factors that impact successful or unsuccessful de-implementation of harmful or wasteful healthcare practices.Trial Registration: Clinicaltrials.gov (NCT05020418)

Prolonged antimicrobial prophylaxis following cardiac device procedures increases preventable harm: insights from the VA CART program

2018 ◽  
Vol 39 (9) ◽  
pp. 1030-1036 ◽  
Author(s):  
Archana Asundi ◽  
Maggie Stanislawski ◽  
Payal Mehta ◽  
Anna E. Barón ◽  
Howard Gold ◽  
...  
Keyword(s):  
Antimicrobial Therapy ◽  
Cardiac Electrophysiology ◽  
Electronic Device ◽  
Antimicrobial Prophylaxis ◽  
Secondary Outcome ◽  
Antimicrobial Use ◽  
Cardiac Device ◽  
Increased Risk ◽  
Preventable Harm ◽  
The Impact

AbstractBackgroundThe rate of cardiovascular implantable electronic device (CIED) infection is increasing coincident with an increase in the number of device procedures. Preprocedural antimicrobial prophylaxis reduces CIED infections; however, there is no evidence that prolonged postprocedural antimicrobials additionally reduce risk. Thus, we sought to quantify the harms associated with this approach.ObjectiveTo measure the association between Clostridium difficile infection (CDI), acute kidney injury (AKI) and receipt of prolonged postprocedural antimicrobials.MethodsCIED procedures entered into the VA Clinical Assessment Reporting and Tracking Electrophysiology (CART-EP) database during fiscal years 2008–2016 were included. The primary outcome was 90-day incidence of CDI and the secondary outcome was the 7-day incidence of AKI. The primary exposure measure was duration of postprocedural antimicrobial therapy. Associations were measured using Cox-proportional hazards and binomial regression.ResultsProlonged postprocedural antimicrobial therapy was identified following 3,331 of 6,497 CIED procedures (51.3%), and the median duration of prophylaxis was 5 days. Prolonged postprocedural antimicrobial use was associated with increased risk of CDI (hazard ratio [HR], 2.90; 95% confidence interval [CI], 1.54–5.46). Of the 27 patients who developed CDI, 11 subsequently died. Postprocedural antimicrobial use with ≥2 antimicrobials was associated with an increased risk of AKI (OR, 4.16; 95% CI, 2.50–6.90). The impact was particularly significant when one of the dual agents prescribed was vancomycin (adjusted OR, 8.41; 95% CI, 5.53–12.79).ConclusionsProlonged antimicrobial prophylaxis following CIED procedures increases preventable harm; this practice should be discouraged in procedural settings such as the cardiac electrophysiology laboratory.

scholarly journals Novel Methodology to Measure Preprocedure Antimicrobial Prophylaxis: Integrating Text Mining With Structured Data

2020 ◽  
Vol 41 (S1) ◽  
pp. s12-s13
Author(s):  
Hillary Mull ◽  
Kelly Stolzmann ◽  
Emily Kalver ◽  
Marlena Shin ◽  
Marin Schweizer ◽  
...  
Keyword(s):  
Antimicrobial Prophylaxis ◽  
High Sensitivity ◽  
Structured Data ◽  
Fiscal Year ◽  
Veterans Health ◽  
Health Administration ◽  
Implementation Barriers ◽  
Cardiac Device ◽  
Device Infection ◽  
Manual Review

Background: Antimicrobial prophylaxis is an evidence-proven strategy for reducing procedure-related infections; however, measuring this key quality metric typically requires manual review, due to the way antimicrobial prophylaxis is documented in the electronic medical record (EMR). Our objective was to combine structured and unstructured data from the Veterans’ Health Administration (VA) EMR to create an electronic tool for measuring preincisional antimicrobial prophylaxis. We assessed this methodology in cardiac device implantation procedures. Methods: With clinician input and review of clinical guidelines, we developed a list of antimicrobial names recommended for the prevention of cardiac device infection. Next, we iteratively combined positive flags for an antimicrobial order or drug fill from structured data fields in the EMR and hits on text string searches of antimicrobial names documented in electronic clinical notes to optimize an algorithm to flag preincisional antimicrobial use with high sensitivity and specificity. We trained the algorithm using existing fiscal year (FY) 2008-15 data from the VA Clinical Assessment Reporting and Tracking-Electrophysiology (CART-EP), which contains manually determined information about antimicrobial prophylaxis. We then validated the performance of the final version of the algorithm using a national cohort of VA patients who underwent cardiac device procedures in FY 2016 or 2017. Discordant cases underwent expert manual review to identify reasons for algorithm misclassification and to identify potential future implementation barriers. Results: The CART-EP dataset included 2,102 procedures at 38 VA facilities with manually identified antimicrobial prophylaxis in 2,056 cases (97.8%). The final algorithm combining structured EMR fields and text-note search results flagged 2,048 of the CART-EP cases (97.4%). Algorithm validation identified antimicrobial prophylaxis in 16,334 of 19,212 cardiac device procedures (87.9%). Misclassifications occurred due to EMR documentation issues. Conclusions: We developed a methodology with high accuracy to measure guideline-concordant use of antimicrobial prophylaxis before cardiac device procedures using data fields present in modern EMRs that does not rely on manual review. In addition to broad applicability in the VA and other healthcare systems with EMRs, this method could be adapted for other procedural areas in which antimicrobial prophylaxis is recommended but comprehensive measurement has been limited to resource-intense manual review.Funding: NoneDisclosures: None

Reducing Broad Spectrum Antimicrobial Use in Extracorporeal Membrane Oxygenation (ECMO): Reduce AMMO Study

2021 ◽  
Author(s):  
Aditya Shah ◽  
Priya Sampathkumar ◽  
Ryan W Stevens ◽  
John K Bohman ◽  
Brian D Lahr ◽  
...  
Keyword(s):  
Time Series ◽  
Extracorporeal Membrane Oxygenation ◽  
Broad Spectrum ◽  
Antimicrobial Prophylaxis ◽  
Current Evidence ◽  
Antimicrobial Use ◽  
Infection Rates ◽  
Interrupted Time Series Analysis ◽  
Membrane Oxygenation ◽  
The Impact

Abstract Background The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. There are currently no guidelines for antimicrobial prophylaxis. We analyzed 7 years of prophylactic antimicrobial use across three time series for patients on ECMO at our institution in the development, improvement, and streamlining of our ECMO antimicrobial prophylaxis protocol. Study design and Methods In this quasi-experimental interrupted time series analysis, we evaluated the impact of an initial ECMO antimicrobial prophylaxis protocol, implemented in 2014, on antimicrobial use and NHSN reportable infection rates. Then, following a revision and streamlining of the protocol in November 2018, we re-evaluated the same metrics. Results Our study population included 338 ICU patients who received ECMO between July 2011 and November 2019. After implementation of the first version of the protocol we did not observe significant changes in antimicrobial use or infection rates in these patients; however, following revision and streamlining of the protocol, we demonstrated a significant reduction in broad spectrum antimicrobial use for prophylaxis in patients on ECMO without any evidence of a compensatory increase in infection rates. Conclusion Our final protocol significantly reduces broad spectrum antimicrobial use for prophylaxis in patients on ECMO. We propose a standard antimicrobial prophylaxis regimen for patients on ECMO based on current evidence and our experience.

Exploration role of volunteerism on the digitisation project: case of the office of the premier in Mpumalanga province, South Africa

2020 ◽  
Vol 40 (1) ◽  
pp. 15-23 ◽  
Author(s):  
Nkholedzeni Sidney Netshakhuma
Keyword(s):  
South Africa ◽  
Best Practice ◽  
Qualitative Interviews ◽  
Successful Implementation ◽  
Youth Empowerment ◽  
Content Type ◽  
Mpumalanga Province ◽  
Volunteer Labor

Purpose The purpose of this paper is to assess the role of volunteerism during the digitisation project by the Office of the Premier in Mpumalanga with a view recommending the best practice. Design/methodology/approach The empirical data was collected through the semi-structured qualitative interviews with the records manager and ten volunteer archivists employed by the Office of the Premier. Findings Local pupils within the Mpumalanga province were recruited to participate in the digitisation project as a form of youth empowerment. The Mpumalanga Provincial Archives was not involved in the digitisation project to ensure that all digitisation specification was in line with the requirement of the provincial archives. Furthermore, a lack of resources to implement the digitisation project was cited as the main stamping block for the successful implementation of the project. Research limitations/implications This paper is limited to the Office of the premier, in the Mpumalanga province. Practical implications Archivists interested in recruiting volunteers on a digitisation project can use this paper to understand the benefits and cost of volunteer labor before putting volunteer projects into practice. Social implications The success of a digitisation project depends on the involvement of the Mpumalanga Provincial archives. Originality/value This paper presents a unique case study in South Africa of a digitisation project staffed with volunteers in the office of the Premier.

scholarly journals 1077. Reduce Anti-Microbial Use in Extracorporeal Membrane Oxygenation: Reduce AMMO Study

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S382-S382
Author(s):  
Aditya Shah ◽  
Prabij Dhungana ◽  
Kirtivardhan Vashistha ◽  
Priya Sampathkumar ◽  
John Bohman ◽  
...  
Keyword(s):  
Infectious Disease ◽  
High Risk ◽  
Extracorporeal Membrane Oxygenation ◽  
Life Support ◽  
Task Force ◽  
Antimicrobial Prophylaxis ◽  
Extracorporeal Life Support ◽  
Antimicrobial Use ◽  
Membrane Oxygenation ◽  
Critically Ill Adults

Abstract Background The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. Patients on ECMO are at high risk for infections, with 20.5% of adults acquiring infections while on ECMO. An Extracorporeal Life Support Organization (ELSO) Infectious Disease Task Force statement concluded that no antibiotic prophylaxis is needed for patients on ECMO though it also noted that this was based on limited data. We implemented an antimicrobial prophylaxis protocol for patients on ECMO at our institution and analyzed antimicrobial use and outcomes in these patients with a pre- and post-analysis. Methods We conducted a retrospective review of 294 patients on ECMO between July 1, 2011 and July 1, 2017. An ECMO antimicrobial prophylaxis guideline was initially implemented on July 1, 2014; there was poor adherence to the guideline and antimicrobial use actually increased. A more restrictive protocol was implemented in November 2018 with input from stakeholders including cardiac surgeons, critical care and infectious disease (ID) providers. We had a cohort of 161 patients before (July 2014–November 2018) and 37 patients after (November 2018–April 2018) the implementation of the updated protocol. We evaluated primary outcomes of gross days of antimicrobial use, percent of antibiotic-free days and days of individual antimicrobial use, adjusted for APACHE scores and ECMO duration. Results When adjusted for days on ECMO, mean antibiotic days decreased after implementation of the protocol; for vancomycin (0.27 vs. 0.02, P < 0.0003), cefepime (0.15 vs. 0.02, P < 0.02), meropenem (0.09 vs. 0, P < 0.02), zosyn (0.16 vs. 0, P < 0.002), caspofungin (0.346, 0.138 P < 0.003). This was accompanied by a nonsignificant increase in mean fluconazole use (0.29 vs. 0.37, P < 0.3). There was no impact on patient mortality or nosocomial infection rate. Additional results can be found in table. Conclusion The use of an antimicrobial prophylaxis protocol in ECMO patients led to improvement in antimicrobial usage without increasing nosocomial infections in a population at a high risk of infection. Disclosures All authors: No reported disclosures.

scholarly journals Understanding circular economy awareness and practices in manufacturing firms

2019 ◽  
Vol 32 (4) ◽  
pp. 563-584 ◽  
Author(s):  
Nikolaos Liakos ◽  
Vikas Kumar ◽  
Siwarit Pongsakornrungsilp ◽  
Jose Arturo Garza-Reyes ◽  
Bhumika Gupta ◽  
...  
Keyword(s):  
Environmental Impact ◽  
Circular Economy ◽  
Economic Benefits ◽  
Resource Scarcity ◽  
Manufacturing Firms ◽  
Academic Community ◽  
The State ◽  
Empirical Literature ◽  
Successful Implementation ◽  
Content Type

Purpose Circular economy (CE) has evolved as a result of the growing environmental awareness, environmental legislation and the need for social responsibility. However, awareness levels of CE are not as high as expected and practices are further behind than they should be, with a significant lack of research around the subject in the literature. Therefore, the purpose of this paper is to examine the current state of awareness levels and the practices around CE in manufacturing firms. Moreover, the study aims to empirically validate one of the earlier proposed CE models. Design/methodology/approach The study adopts a quantitative survey questionnaire based approach. More than 500 people from various manufacturing organisations were contacted directly over a 40-day long sampling process through the FAME database, personal contacts and LinkedIn. The survey resulted in 103 completed responses. Given the exploratory nature of the study, the data were mainly analysed using descriptive statistics. To validate the CE model, a correlation analysis was also conducted. Findings The research findings show that with the growing emphasis on CE across the globe by governing bodies, firms are becoming more aware of CE practices. The analysis also shows some useful insights on the state of each of the pillars (economic benefits, environmental impact and resource scarcity) of CE. The findings also indicate that the environmental impact pillar of CE is at a more developed state than the other two pillars which are, mostly, in a research state. Research limitations/implications The study provides manufacturing firms with a thorough understanding of the state of CE practices and importance of its successful implementation. The findings of the study advocates consideration of all three pillars of CE by managers as a guide to plan for an efficient strategy around CE implementation. Moreover, our study adds to existing efforts by the academic community to raise the awareness towards CE practice among all relevant stakeholders. The findings of this study are based on the responses from a limited 103 survey responses from manufacturing firms. Originality/value This study adds to the very limited empirical literature on CE awareness and practices in manufacturing firms. This is also one of the first studies attempting to empirically validate an existing CE model.

scholarly journals Impact of a multifaceted antimicrobial stewardship program: A front-line ownership driven quality improvement project in a large urban emergency department

CJEM ◽  
2017 ◽  
Vol 19 (06) ◽  
pp. 441-449 ◽  
Author(s):  
Adam Jonathan Kaufman ◽  
Janine McCready ◽  
Jeff Powis
Keyword(s):  
Emergency Department ◽  
Antimicrobial Stewardship ◽  
Inpatient Setting ◽  
Successful Implementation ◽  
Antimicrobial Use ◽  
Front Line ◽  
Improvement Project ◽  
Antibiotic Overuse ◽  
Defined Daily Doses ◽  
Stewardship Program

AbstractBackgroundAntibiotic overuse has promoted growing rates of antimicrobial resistance and secondary antibiotic-associated infections such asClostridium difficile(C. difficile). Antimicrobial stewardship programs (ASPs) are effective in reducing antimicrobial use in the inpatient setting; however, the unique environment of the emergency department (ED) lends itself to challenges for successful implementation. Front-line ownership (FLO) methodology has been shown to be a potentially effective strategy for the implementation of inpatient ASPs through an iterative multi-pronged approach driven by front-line providers.ObjectiveTo determine whether a FLO approach to antimicrobial stewardship in the ED can alter antimicrobial usage.MethodsInterventions were driven by ED physicians and facilitated by Infectious Diseases Division physicians from the hospital’s ASP using FLO principles. Measured end points included antibiotic usage in the ED as measured by defined daily doses, and rates of urine culture sent from the ED.ResultsThere was a step-wise significant reduction in the use of azithromycin (p=0.006), ceftriaxone (p=0.045), ciprofloxacin (p=0.034), and moxifloxacin (p=0.008). There was also a significant reduction in rates of urine cultures (p&lt;0.001) by 2.26 urine cultures per 100 ED patient visits.ConclusionsFLO offers a promising approach to successful implementation of an ASP in the ED. Future studies would be important to evaluate the generalizability of the FLO approach to ASP development in other EDs and to determine strategies to improve the sustainability of reductions in antimicrobial use.

Infection and Antimicrobial Use in Laparoscopic Cholecystectomy

1999 ◽  
Vol 20 (9) ◽  
pp. 624-626 ◽  
Author(s):  
Maryanne McGuckin ◽  
Judy A. Shea ◽  
J. Sanford Schwartz
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Surgical Site Infection ◽  
Infection Rate ◽  
Chart Review ◽  
Antimicrobial Prophylaxis ◽  
Retrospective Chart Review ◽  
Low Risk ◽  
Antimicrobial Use ◽  
Site Infection ◽  
Surgical Site Infection Rate

AbstractRetrospective chart review of 1,702 patients undergoing laparoscopic cholecystectomy (LC) revealed an overall infection rate of 2.3% and a surgical-site infection rate of 0.4%. Preoperative antimicrobial prophylaxis was received by 79% of patients, but only 33% of these received the agent within 1 hour or less prior to surgery. These facts suggest that antimicrobial prophylaxis may not be necessary for low-risk LC patients.

scholarly journals Physicians’ experiences of SBIRT training and implementation for SUD management in primary care in the UAE: a qualitative study

2017 ◽  
Vol 19 (04) ◽  
pp. 344-354
Author(s):  
Christiane Pflanz-Sinclair ◽  
Catriona Matheson ◽  
Christine M. Bond ◽  
Amna Almarzouqi ◽  
Amanda J. Lee ◽  
...  
Keyword(s):  
Primary Care ◽  
Substance Use ◽  
Qualitative Study ◽  
Primary Care Physicians ◽  
Substance Misuse ◽  
Care Pathway ◽  
Controlled Trial ◽  
Qualitative Interviews ◽  
Successful Implementation ◽  
Cultural Issues

AimThe objective of this paper is to present a qualitative study of introducing substance misuse screening using the Screening Brief Intervention and Referral to Treatment (SBIRT) model, in primary care in Abu Dhabi.BackgroundSubstance misuse in the UAE is an increasing problem. However religious beliefs and fear of legal consequences have prevented this topic from being openly discussed, risk levels identified through screening and treatment options offered.MethodsA controlled trial was undertaken which included a qualitative process study which is reported here. Qualitative interviews with primary care physicians from two intervention clinics were undertaken to explore their views, experiences and attitudes towards substance misuse management in their clinic. Physicians were trained on SBIRT and on the research project process and documentation. At completion of the project, 10 months after the training, physicians (n=17) were invited to participate in an interview to explore their experiences of training and implementation of SBIRT. Interviews were recorded and transcribed. Inductive thematic coding was applied.FindingsIn total, 11 physicians were interviewed and three main themes emerged: (1) The SBIRT screening project, (2) cultural issues and (3) patient follow-up. Findings revealed a general willingness toward the concept of screening and delivering brief interventions in primary care although increased workload and uncertainties about remuneration for the service may be a barrier to future implementation. There was a perceived problem of substance misuse that was not currently being met and a strong perception that patients were not willing to reveal substance use due cultural barriers and fear of police involvement. In conclusion this qualitative process evaluation provided essential insight into implementing SBIRT in the Middle East. In conclusion, despite physician willingness and a clinical need for a substance misuse care pathway, the reluctance among patients to admit to substance use in this culture needs to be addressed to enable successful implementation.

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