scholarly journals Implementation of a Clostridioides difficile prevention bundle: Understanding common, unique, and conflicting work system barriers and facilitators for subprocess design

2019 ◽  
Vol 40 (8) ◽  
pp. 880-888 ◽  
Author(s):  
Jackson S. Musuuza ◽  
Ann Schoofs Hundt ◽  
Pascale Carayon ◽  
Karly Christensen ◽  
Caitlyn Ngam ◽  
...  
Keyword(s):  
Systems Engineering ◽  
Diagnostic Testing ◽  
Barriers And Facilitators ◽  
Successful Implementation ◽  
Work System ◽  
Clostridioides Difficile ◽  
Contact Isolation ◽  
Management Procedures ◽  
Algorithmic Approaches ◽  
Environmental Disinfection

AbstractObjective:Clostridioides difficile (C. difficile) poses a major challenge to the healthcare system. We assessed factors that should be considered when designing subprocesses of a C. difficile infection (CDI) prevention bundle.Design:Phenomenological qualitative study.Methods:We conducted 3 focus groups of environmental services (EVS) staff, physicians, and nurses to assess their perspectives on a CDI prevention bundle. We used the Systems Engineering Initiative for Patient Safety (SEIPS) model to examine 5 subprocesses of the CDI bundle: diagnostic testing, empiric isolation, contact isolation, hand hygiene, and environmental disinfection. We coded transcripts to the 5 SEIPS elements and ensured scientific rigor. We sought to determine common, unique, and conflicting factors across stakeholder groups and subprocesses of the CDI bundle.Results:Each focus group lasted 1.5 hours on average. Common work-system barriers included inconsistencies in knowledge and practice of CDI management procedures; increased workload; poor setup of aspects of the physical environment (eg, inconvenient location of sinks); and inconsistencies in CDI documentation. Unique barriers and facilitators were related to specific activities performed by the stakeholder group. For instance, algorithmic approaches used by physicians facilitated timely diagnosis of CDI. Conflicting barriers or facilitators were related to opposing objectives; for example, clinicians needed rapid placement of a patient in a room while EVS staff needed time to disinfect the room.Conclusions:A systems engineering approach can help to holistically identify factors that influence successful implementation of subprocesses of infection prevention bundles.

scholarly journals Team Cognition as a Barrier and Facilitator in Care Transitions: Implications for Work System Design

2019 ◽  
Vol 63 (1) ◽  
pp. 648-652
Author(s):  
Abigail R. Wooldridge ◽  
Pascale Carayon ◽  
Peter Hoonakker ◽  
Bat-Zion Hose ◽  
Thomas B. Brazelton ◽  
...  
Keyword(s):  
Patient Safety ◽  
System Design ◽  
Systems Engineering ◽  
Care Transitions ◽  
Pediatric Trauma ◽  
Barriers And Facilitators ◽  
Distributed Teams ◽  
Future Research ◽  
Team Cognition ◽  
Work System

Inpatient care of pediatric trauma patients includes care transitions, including from emergency department (ED) to operating room (OR), OR to pediatric intensive care unit (PICU) and ED to PICU, which are important to patient safety and quality of care. Previous research identified work system barriers and facilitators in these transitions; the most common related to team cognition. We conducted interviews with 18 healthcare professionals to better understand how work system design influences team cognition barriers and facilitators. Using Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling, we identified when each barrier/facilitator occurred. The ED to OR transition had more barriers in transition preparation, while OR to PICU had more facilitators in the transition. Future research should explore solutions to support team cognition early in the ED to OR transition, such as designing a technology to be used by distributed teams.

scholarly journals Impact of Two-Step Testing Algorithm on Reducing Hospital-Onset Clostridioides difficile Infections

2021 ◽  
Vol 1 (S1) ◽  
pp. s42-s43
Author(s):  
Bhagyashri Navalkele ◽  
Wendy Winn ◽  
Sheila Fletcher ◽  
Regina Galloway ◽  
Jason Parham ◽  
...  
Keyword(s):  
Medical Center ◽  
Molecular Testing ◽  
Toxin A ◽  
Clostridioides Difficile ◽  
Contact Isolation ◽  
Academic Center ◽  
Mississippi Medical ◽  
True Infection ◽  
Testing Algorithm ◽  
The University

Clostridioides difficile infection (CDI) is one of the leading causes of hospital–onset infections. Clinically distinguishing true CDI versus colonization with C. difficile is challenging and often requires reliable and rapid molecular testing methods. At our academic center, we implemented a 2-step testing algorithm to help identify true CDI cases. The University of Mississippi Medical Center is a 700+ bed academic facility located in Jackson, Mississippi. Hospital-onset (HO) CDI was defined based on NHSN Laboratory Identified (LabID) event as the last positive C. difficile test result performed on a specimen using a multistep testing algorithm collected >3 calendar days after admission to the facility. HO-CDI data were collected from all inpatient units except the NICU and newborn nursery. HO-CDI outcomes were assessed based on standardized infection ratio (SIR) data. In May 2020, we implemented a 2-step testing algorithm (Figure 1). All patients with diarrhea underwent C. difficile PCR testing. Those with positive C. difficile PCR test were reflexed to undergo enzyme immunoassay (EIA) glutamate dehydrogenase antigen (Ag) testing and toxin A and B testing. The final results were reported as colonization (C. difficile PCR+/EIA Ag+/Toxin A/B−) or true CDI case (C. difficile PCR+/EIA +/Toxin A/B +) or negative (C. difficile PCR−). All patients with colonization or true infection were placed under contact isolation precautions until diarrhea resolution for 48 hours. During the preintervention period (October 2019–April 2020), 25 HO-CDI cases were reported compared to 8 cases in the postintervention period (June 2020–December 2020). A reduction in CDI SIR occurred in the postintervention period (Q3 2020–Q4 2020, SIR 0.265) compared to preintervention period (Q4 2019–Q1 2020, SIR 0.338) (Figure 2). We successfully reduced our NHSN HO-CDI SIR below the national average after implementing a 2-step testing algorithm for CDI. The 2-step testing algorithm was useful for antimicrobial stewardship to guide appropriate CDI treatment for true cases and for infection prevention to continue isolation of infected and colonized cases to reduce the spread of C. difficile spores.Funding: NoDisclosures: None

scholarly journals Investigating the barriers and facilitators to implementing mental health first aid in the workplace: a qualitative study

2020 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Melanie Jay Narayanasamy ◽  
Louise Thomson ◽  
Carol Coole ◽  
Fiona Nouri ◽  
Avril Drummond
Keyword(s):  
Mental Health ◽  
Good Practice ◽  
First Aid ◽  
Barriers And Facilitators ◽  
Successful Implementation ◽  
Mental Health First Aid ◽  
Structured Interviews ◽  
Content Type ◽  
Factors Affecting ◽  
Employee Characteristics

Purpose There has been little research into the use and efficacy of Mental Health First Aid (MHFA) across UK workplaces. This paper aims to investigate the implementation of MHFA across six UK organisations, identifying key barriers and facilitators. Design/methodology/approach Twenty-seven workplace representatives were recruited from six organisations through purposive sampling and took part in semi-structured interviews exploring their experiences of workplace MHFA. The data underwent thematic analysis, identifying key themes around implementation. Findings Implementation varied across organisations, including different reasons for initial interest in the programme, and variable ways that MHFA-trained employees operated post-training. Key barriers to successful implementation included negative attitudes around mental health, the perception that MHFA roles were onerous, and employees’ reluctance to engage in the MHFA programme. Successful implementation was perceived to be based on individual qualities of MHFA instructors and good practice demonstrated by trained individuals in the workplace. The role of the inner organisational setting and employee characteristics were further highlighted as barriers and facilitators to effective implementation. Research limitations/implications MHFA is a complex intervention, presenting in different ways when implemented into complex workplace settings. As such, traditional evaluation methods may not be appropriate for gaining insights into its effectiveness. Future evaluations of workplace MHFA must consider the complexity of implementing and operationalising this intervention in the workplace. Originality/value This study is the first to highlight the factors affecting successful implementation of MHFA across a range of UK workplaces.

scholarly journals 2373. Impact of a Change in Testing Strategy for Clostridioides difficile Infection on a Publicly Reported Metric and Treatment Days of Therapy

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S818-S819
Author(s):  
Ryan Miller ◽  
Jose A Morillas ◽  
Joanne Sitaras ◽  
Jacob Bako ◽  
Elizabeth A Neuner ◽  
...  
Keyword(s):  
Health System ◽  
Diagnostic Testing ◽  
Cleveland Clinic ◽  
Public Reporting ◽  
Testing Strategy ◽  
Clostridioides Difficile ◽  
Days Of Therapy ◽  
Before And After ◽  
Clostridioides Difficile Infection ◽  
The Impact

Abstract Background In an effort to optimize diagnostic testing for Clostridioides difficile infection (CDI) our health system changed from stand-alone PCR testing to a “2-step” approach wherein all positive PCR results reflexed to an EIA. We report the effects of this change on publicly reported CDI metrics and treatment days of therapy (DOT). Methods The setting includes 10 Cleveland Clinic Health System hospitals in northeast Ohio and one in Florida. On June 12, 2018, 9 NE Ohio hospitals changed from PCR alone to PCR followed by EIA. Stand-alone PCR testing remained at one and GDH / EIA / PCR for discordant for another. Testing volumes were obtained from the microbiology laboratory. C. difficile LabID event SIRs were obtained from NHSN. Public reporting interpretative categories were identified based on SIR for second half of 2018. DOT for CDI agents were obtained from an antimicrobial stewardship database. Results Among hospitals that changed strategy the volume of PCR testing and the percent PCR + was similar between time periods. EIA positivity ranged from 23% to 53%. 4/11 hospitals improved their public reporting category: 3/9 that changed testing strategy and 1/2 that did not (Table 1). Two of 3 that changed strategy and improved public reporting also had a decrease in DOT. DOT increased in the 2 hospitals that did not change strategy. Conclusion Six months after adopting a 2-step CDI testing strategy 7 of 9 hospitals had a lower SIR with 3 also demonstrating an improvement in public reporting category favorably impacting reputational and reimbursement risk for our healthcare system. CDI agent DOT was similar before and after the change. The impact of choice of test on publicly reported metrics demonstrates the difficulty of utilizing a proxy for hospital onset CDI, the CDI LabID event, as a measure of quality of care provided. Disclosures All authors: No reported disclosures.

scholarly journals 2055. Action: A Year in the Lives of Consultant Pharmacists Working on Antimicrobial Stewardship in Long-Term Care Facilities

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S692-S693
Author(s):  
Philip Chung ◽  
Alex Neukirch ◽  
Rebecca J Ortmeier ◽  
Scott Bergman ◽  
Mark E Rupp ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
First Generation ◽  
Long Term Care ◽  
Diagnostic Testing ◽  
Drug Regimen ◽  
Term Care ◽  
Clostridioides Difficile ◽  
Care Facilities ◽  
Tract Infections

Abstract Background The CDC recommends consultant pharmacists (CP) support antimicrobial stewardship (AS) activities in long-term care facilities (LTCF) by reviewing antimicrobial appropriateness. We initiated a project training CP from a regional long-term care pharmacy to support AS implementation in LTCF. Methods CP were trained to evaluate the appropriateness of all systemic antimicrobial therapy (AT) and provide prescriber feedback during their monthly drug regimen review (DRR). An electronic database was developed to facilitate data reporting. Antimicrobial use (AU) and adverse events (AE) from 32 LTCF were analyzed for 2018 using descriptive statistics. Results A total of 5327 courses of AT with a median duration of 7 days (IQR 5–10) were reviewed. The majority of AT was started in the LTCF (55%) but was also initiated in hospitals (24%), clinics (11%) and emergency departments (2%). Of 2926 AT started in LTCF, 36% were based on nurse evaluation (NE) while 33% began after prescriber evaluation (PE). Fluoroquinolones (FQ) and first-generation cephalosporins were the most commonly prescribed agents (Table 1). Treatment or prophylaxis of urinary tract infections accounted for 40% of AU (Figure 1). Diagnostic testing was associated with 37% of AT courses. Urine cultures were the most frequent test performed (81%). Overall, 41% of AT was determined to be inappropriate resulting in > 800 feedback letters sent to prescribers. Unnecessary antibiotic starts (based on revised Mc Geer or Loeb’s criteria) were identified as the most common reason (Figure 2). AT appropriateness varied depending on the setting in which it was initiated. A majority (87%) of AT initiated in hospitals was found to be appropriate with 56% and 46% appropriate for ED and clinic starts. Appropriateness of LTCF initiated AT was 49% (59% after PE and 42% after NE). AE were associated with 3% of AT with allergic reactions and Clostridioides difficile infections occurring with 0.4% and 0.7% of AT, respectively. AE were most frequently associated with folate antagonists (5%) and FQ (3%). Conclusion This study demonstrates many AU improvement opportunities exist in LTCF and CP can play an important role in identifying them if trained in AS principles. CP should review all AU for appropriateness and provide data to inform AS efforts in LTCF. Disclosures All authors: No reported disclosures.

scholarly journals Reducing C. difficile in children: An agent-based modeling approach to evaluate intervention effectiveness

2020 ◽  
Vol 41 (5) ◽  
pp. 522-530 ◽  
Author(s):  
Anna K. Barker ◽  
Elizabeth Scaria ◽  
Oguzhan Alagoz ◽  
Ajay K. Sethi ◽  
Nasia Safdar
Keyword(s):  
Hand Hygiene ◽  
Infection Prevention ◽  
Tertiary Care ◽  
Substantial Reduction ◽  
Patient Transfers ◽  
Agent Based ◽  
Contact Precautions ◽  
Clostridioides Difficile ◽  
Effective Interventions ◽  
Environmental Disinfection

AbstractObjective:Clostridioides difficile infection (CDI) is rapidly increasing in children’s hospitals nationwide. Thus, we aimed to compare the effectiveness of 9 infection prevention interventions and 6 multiple-intervention bundles at reducing hospital-onset CDI and asymptomatic C. difficile colonization.Design:Agent-based simulation model of C. difficile transmission.Setting:Computer-simulated, 80-bed freestanding, tertiary-care pediatric hospital, including 8 identical wards with 10 single-bed patient rooms each.Participants:The model includes 5 distinct agent types: patients, visitors, caregivers, nurses, and physicians.Interventions:Daily and terminal environmental disinfection, screening at admission, reduced intrahospital patient transfers, healthcare worker (HCW), visitor, and patient hand hygiene, and HCW and visitor contact precautions.Results:The model predicted that daily environmental disinfection with sporicidal product, combined with screening for asymptomatic C. difficile at admission, was the most effective 2-pronged infection prevention bundle, reducing hospital-onset CDI by 62.0% and asymptomatic colonization by 88.4%. Single-intervention strategies, including daily disinfection, terminal disinfection, asymptomatic screening at admission, HCW hand hygiene, and patient hand hygiene, as well as decreasing intrahospital patient transfers, all also reduced both hospital-onset CDI and asymptomatic colonization in the model. Visitor hand hygiene and visitor and HCW contact precautions were not effective at reducing either measure.Conclusions:Hospitals can achieve substantial reduction in hospital-onset CDIs by implementing a small number of highly effective interventions.

scholarly journals Human Factors/Ergonomics Work System Analysis of Patient Work: State of the Science and Future Directions

2020 ◽  
Author(s):  
Nicole E Werner ◽  
Siddarth Ponnala ◽  
Nadia Doutcheva ◽  
Richard J Holden
Keyword(s):  
Human Factors ◽  
Systems Engineering ◽  
System Analysis ◽  
The United States ◽  
Empirical Literature ◽  
Study Patient ◽  
Study Objective ◽  
Work System ◽  
System Models ◽  
Patient Work

Abstract Purpose To demonstrate the use and value of the Human Factors/Ergonomics-based Systems Engineering Initiative for Patient Safety (SEIPS) family of work system models for studying and improving patient work. Data Sources : We conducted a review of the published empirical literature applying the SEIPS family of work system models for patient work. Study Selection Included studies had to: apply one of the SEIPS family of work system models to study patient work; be published in a peer-reviewed journal in English; and include analysis of data. We identified 16 articles that met our inclusion criteria. Data Extraction For each study we extracted: settings and situations in which models were applied; research design; study methods; model(s) used; type and number of study participants; study objective(s); whether the study included an intervention; specific aspects of the model used; knowledge generated about patient work; and benefits of using the models. Results of data synthesis Our analysis revealed that a majority of studies were conducted in the United States, used qualitative or mixed methods, and employed a variety of data collection techniques to study adult patient populations with chronic illness and their informal caregivers and healthcare providers performing patient work in the home and clinical setting. The studies resulted in a variety of useful products, demonstrating several benefits of using the models. Conclusion Our review has demonstrated the value of using the SEIPS family of work systems models to study and improve patient and family contributions to health-related work.

scholarly journals Barriers and Facilitators to Implementation of Medication Decision Support Systems in Electronic Medical Records: Mixed Methods Approach Based on Structural Equation Modeling and Qualitative Analysis (Preprint)

2020 ◽  
Author(s):  
Se Young Jung ◽  
Hee Hwang ◽  
Keehyuck Lee ◽  
Ho-Young Lee ◽  
Eunhye Kim ◽  
...  
Keyword(s):  
Structural Equation Modeling ◽  
Decision Support ◽  
Quantitative Analysis ◽  
Qualitative Analysis ◽  
Structural Equation ◽  
Adverse Drug Events ◽  
Ease Of Use ◽  
Barriers And Facilitators ◽  
Equation Modeling ◽  
Successful Implementation

BACKGROUND Adverse drug events (ADEs) resulting from medication error are some of the most common causes of iatrogenic injuries in hospitals. With the appropriate use of medication, ADEs can be prevented and ameliorated. Efforts to reduce medication errors and prevent ADEs have been made by implementing a medication decision support system (MDSS) in electronic health records (EHRs). However, physicians tend to override most MDSS alerts. OBJECTIVE In order to improve MDSS functionality, we must understand what factors users consider essential for the successful implementation of an MDSS into their clinical setting. This study followed the implementation process for an MDSS within a comprehensive EHR system and analyzed the relevant barriers and facilitators. METHODS A mixed research methodology was adopted. Data from a structured survey and 15 in-depth interviews were integrated. Structural equation modeling was conducted for quantitative analysis of factors related to user adoption of MDSS. Qualitative analysis based on semistructured interviews with physicians was conducted to collect various opinions on MDSS implementation. RESULTS Quantitative analysis revealed that physicians’ expectations regarding ease of use and performance improvement are crucial. Qualitative analysis identified four significant barriers to MDSS implementation: alert fatigue, lack of accuracy, poor user interface design, and lack of customizability. CONCLUSIONS This study revealed barriers and facilitators to the implementation of MDSS. The findings can be applied to upgrade MDSS in the future.

scholarly journals Barriers and facilitators to implementation of oral rehydration therapy in low- and middle-income countries: A systematic review

PLoS ONE ◽  
2021 ◽  
Vol 16 (4) ◽  
pp. e0249638
Author(s):  
Obidimma Ezezika ◽  
Apira Ragunathan ◽  
Yasmine El-Bakri ◽  
Kathryn Barrett
Keyword(s):  
Systematic Review ◽  
Implementation Research ◽  
Oral Rehydration Therapy ◽  
Barriers And Facilitators ◽  
World Health ◽  
Successful Implementation ◽  
Middle Income ◽  
Oral Rehydration ◽  
Middle Income Countries ◽  
Low And Middle Income

Background Oral rehydration therapy (ORT) is an effective and cheap treatment for diarrheal disease; globally, one of the leading causes of death in children under five. The World Health Organization launched a global campaign to improve ORT coverage in 1978, with activities such as educational campaigns, training health workers and the creation of designate programming. Despite these efforts, ORT coverage remains relatively low. The objective of this systematic review is to identify the barriers and facilitators to the implementation of oral rehydration therapy in low and middle-income countries. Methods A comprehensive search strategy comprised of relevant subject headings and keywords was executed in 5 databases including OVID Medline, OVID Embase, OVID HealthStar, Web of Science and Scopus. Eligible studies underwent quality assessment, and a directed content analysis approach to data extraction was conducted and aligned to the Consolidated Framework for Implementation Research (CFIR) to facilitate narrative synthesis. Results The search identified 1570 citations and following removal of duplicates as well as screening according to our inclusion/exclusion criteria, 55 articles were eligible for inclusion in the review. Twenty-three countries were represented in this review, with India, Bangladesh, Egypt, Nigeria, and South Africa having the most representation of available studies. Study dates ranged from 1981 to 2020. Overarching thematic areas spanning the barriers and facilitators that were identified included: availability and accessibility, knowledge, partnership engagement, and design and acceptability. Conclusion A systematic review of studies on implementation of ORT in low- and middle-income countries (LMICs) highlights key activities that facilitate the development of successful implementation that include: (1) availability and accessibility of ORT, (2) awareness and education among communities, (3) strong partnership engagement strategies, and (4) adaptable design to enhance acceptability. The barriers and facilitators identified under the CIFR domains can be used to build knowledge on how to adapt ORT to national and local settings and contribute to a better understanding on the implementation and use of ORT in LMICs. The prospects for scaling and sustaining ORT (after years of low use) will increase if implementation research informs local applications, and implementers engage appropriate stakeholders and test assumptions around localized theories of change from interventions to expected outcomes. Registration A protocol for this systematic review was developed and uploaded onto the PROSPERO international prospective register of systematic reviews database (Registration number: CRD420201695).

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