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Background: Veterans Health Administration (VHA) community living centers (CLCs) provide postacute and long-term care. CLC veterans visit myriad locations outside their rooms (eg, rehabilitation, dialysis). Pathogen transmission during out-of-room visits is unknown. Methods: We recruited newly admitted veterans at 3 CLCs. After obtaining informed consent, we cultured nares, groin, hands, and 7 surfaces in the patient rooms. We accompanied veterans to up to 5 out-of-room visits and cultured patients’ hands and surfaces they touched. We tested for multidrug-resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and quinolone, carbapenem, and/or ceftazidime-resistant gram-negative bacteria (R-GNB). We defined transmission as a positive culture following an initial negative culture during the same visit. Results: We enrolled 137 veterans (median follow-up, 29 days; mean, 5.9 visits); 97% were postacute patients. We conducted 539 patient-room sampling visits (mean, 3.9 per veteran; 5,490 swabs) and accompanied 97 veterans to 266 out-of-room sampling visits (mean, 2.7 per veteran; 2,360 swabs). Of 137 patients, 47 (35%) were colonized with an MDRO at enrollment and 74 (58%) of 128 patients were colonized on any follow-up patient-room visits. Of 133 patients, 55 (41%) acquired a new MDRO, most often VRE (31 of 97, 32%). In patient rooms, toilet seats [114 (21%) of 538], curtains [101 (19%) of 530] and bedrails [98 (18%) of 539] were most frequently contaminated. Among 266 out-of-room visits, 17% had surfaces contaminated with MDROs, most commonly involving dialysis [4 (31%) of 13], radiology [2 (25%) of 8], and rehabilitation therapy [29 (18%) of 159] (Fig. 1).Transmission of MDROs during out-of-room visits was common and occurred in 18% of visits with 8% (9 MRSA and 12 VRE) acquiring a new MDRO on their hands and 12% (9 MRSA and 23 VRE) of MDRO transmission occurring from hands to a surface that the patient touched (Fig. 1). In 18 (58%) of 31 cases, the organism transmitted to a surface was on patient hands at the start of the visit. Transmission was most common during visits to dialysis (3 to patients and 2 to surfaces), radiology (1 to a patient and 2 to surfaces), and rehabilitation therapy (13 to patients and 21 to surfaces) (Fig. 2). Conclusions: New MDRO acquisition during VHA CLC stay was common, and nearly one-fifth of out-of-room visits resulted in MDRO transmission. Our analyses suggest that veterans’ hands may shed MDROs (MRSA and VRE) to surfaces. Interventions to reduce MDRO transmission during visits for rehabilitation, dialysis, and other therapies are needed.

BackgroundEnd-stage kidney disease (ESKD) is treated with dialysis or kidney transplantation, with most patients with ESKD receiving in-center hemodialysis treatment. This life-saving treatment can result in cardiovascular and hemodynamic instability, with the most common form being low blood pressure during the dialysis treatment (intradialytic hypotension [IDH]). IDH is a complication of hemodialysis that can involve symptoms such as fatigue, nausea, cramping, and loss of consciousness. IDH increases risks of cardiovascular disease and ultimately hospitalizations and mortality. Provider-level and patient-level decisions influence the occurrence of IDH; thus, IDH may be preventable in routine hemodialysis care. ObjectiveThis study aims to evaluate the independent and comparative effectiveness of 2 interventions—one directed at hemodialysis providers and another for patients—in reducing the rate of IDH at hemodialysis facilities. In addition, the study will assess the effects of interventions on secondary patient-centered clinical outcomes and examine factors associated with a successful implementation of the interventions. MethodsThis study is a pragmatic, cluster randomized trial to be conducted in 20 hemodialysis facilities in the United States. Hemodialysis facilities will be randomized using a 2 × 2 factorial design, such that 5 sites will receive a multimodal provider education intervention, 5 sites will receive a patient activation intervention, 5 sites will receive both interventions, and 5 sites will receive none of the 2 interventions. The multimodal provider education intervention involved theory-informed team training and the use of a digital, tablet-based checklist to heighten attention to patient clinical factors associated with increased IDH risk. The patient activation intervention involves tablet-based, theory-informed patient education and peer mentoring. Patient outcomes will be monitored during a 12-week baseline period, followed by a 24-week intervention period and a 12-week postintervention follow-up period. The primary outcome of the study is the proportion of treatments with IDH, which will be aggregated at the facility level. Secondary outcomes include patient symptoms, fluid adherence, hemodialysis adherence, quality of life, hospitalizations, and mortality. ResultsThis study is funded by the Patient-Centered Outcomes Research Institute and approved by the University of Michigan Medical School’s institutional review board. The study began enrolling patients in January 2023. Initial feasibility data will be available in May 2023. Data collection will conclude in November 2024. ConclusionsThe effects of provider and patient education on reducing the proportion of sessions with IDH and improving other patient-centered clinical outcomes will be evaluated, and the findings will be used to inform further improvements in patient care. Improving the stability of hemodialysis sessions is a critical concern for clinicians and patients with ESKD; the interventions targeted to providers and patients are predicted to lead to improvements in patient health and quality of life. Trial RegistrationClinicalTrials.gov NCT03171545; https://clinicaltrials.gov/ct2/show/NCT03171545 International Registered Report Identifier (IRRID)PRR1-10.2196/46187

This article explores the utility of implementation science (IS) as a method to promote the effective uptake of antimicrobial stewardship processes. Elements of IS can be readily incorporated into QI work and used as a platform to extend stewardship reach. As stewards are stretched to do more, IS can be a potential vehicle to ensure that our collective work is impactful, sustainable, and contributes more broadly to clinically relevant improvements.

Background: Outpatient parenteral antimicrobial therapy (OPAT) involves the administration of intravenous antimicrobial therapy outside the hospital. The literature suggests that inpatient providers are often unaware of OPAT programs and may not engage this multidisciplinary group in a timely fashion, leading to potentially inappropriate OPAT use. However, few studies have directly addressed this issue. We characterized current practices for coordinating OPAT and assessed provider understanding of OPAT services. We also conducted an exploratory analysis of placement of a peripherally inserted central catheter (PICC) consultation prior to an infectious disease (ID) consultation as a proxy for potentially avoidable OPAT use. Methods: This study was conducted between September and December 2021 at the Ann Arbor VA Healthcare System. All charts (n = 212) in which a consultation for a PICC was placed between January and September 2021 were reviewed, including free-text data entered by patient teams and inpatient progress notes in the days leading up to and following PICC consultation. Additionally, inpatient providers were surveyed using an online format regarding knowledge, utilization, and perceptions of OPAT. Results: Of the 212 charts reviewed, 108 patient encounters resulted in PICC placement; 80 (74.1%) were placed for the indication of home IV antibiotics. Of these, 3 (4.0%) had the PICC consult placed prior to the ID consultation. Of the 104 PICC consultations that were cancelled, 9 (8.7%) were cancelled because the ID staff did not recommend home IV antibiotics. Other reasons for cancellation included alternative device placement, duplicate order, referral to interventional radiology, failure to meet criteria, or unsuccessful placement. Of the 285 inpatient providers sent the electronic survey, 121 (46.9%) completed at least some portion. Overall, 17 respondents (14.0%) were familiar with the acronym OPAT; however, only 10 were able to expand the acronym correctly. Of the 118 respondents asked about their familiarity with the OPAT program at the local institution, 98 (83.1%) were not familiar at all or were only slightly familiar with the program. In contrast, 7 respondents (6.0%) were very or extremely familiar with the OPAT program. Conclusions: Further education and structural interventions are necessary to improve inpatient providers’ awareness and early engagement of local OPAT programs to ensure appropriate OPAT use. An educational intervention with an informative flowchart diagramming the steps for engaging the OPAT team could raise awareness and improve engagement when potential OPAT needs are identified (Fig. 1).

Abstract Background Hemodialysis sessions frequently become unstable from complications such as intradialytic hypotension and untoward symptoms. Previous patient safety initiatives promote prevention of treatment complications; yet, they have placed little specific focus on avoidable session instability. A patient-centered definition of session instability grounded in patient experiences, and an understanding of patient perceptions of causes and solutions to instability, may enable such efforts. Methods Twenty-five participants participated in three focus groups and/or a survey. They were purposively sampled for variation in region of residence, and sensitivity to patient well-being. Focus group recordings were analyzed using descriptive coding, in vivo coding, and thematic analysis. Results Patients define unstable sessions (“bad runs”) as those in which they experience severe discomfort or unanticipated events that interfere with their ability to receive therapy. Bad runs were characterized primarily by cramping, low blood pressure (“crashing”), cannulation-related difficulties (“bad sticks”), and clotting of the dialysis circuit or vascular access. Patients believed that cramping and crashing could be explained by both patient and clinician behavior: patient fluid consumption and providers’ fluid removal goals. Patients felt that the responsibility for cannulation-related problems lay with dialysis staff, and they asked for different staff or self-cannulated as solutions. Clotting was viewed as an idiosyncratic issue with one’s body, and perceived solutions were clinician-driven. Patients expressed concern about “bad runs” on their ability to achieve fluid balance. Conclusions Findings point to novel priorities for efforts to enhance hemodialysis session stability, and areas in which patients can be supported to become involved in such efforts.

Abstract Objective To examine the extent to which acute care hospitals in the Netherlands have adopted recommended practices to prevent catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection (CDI). Methods Between 18 July 2017 and 31 October 2017, we surveyed the infection prevention teams of all acute care hospitals in the Netherlands. The survey instrument was based on the ‘Translating Healthcare-Associated Infection Prevention Research into Practice’ (TRIP) questionnaire and adapted to the Dutch context. Descriptive statistics were used to examine the reported regular use of CAUTI, CLABSI, VAP, and CDI prevention practices as well as the hospital characteristics. Results Out of 72 eligible hospitals, 47 (65.3%) responded. Surveillance systems for monitoring CAUTI, CLABSI, VAP, and CDI were present in 17.8, 95.4, 26.2, and 77.3% of hospitals, respectively. Antimicrobial stewardship programs have been established in 91.5% of participating hospitals. For CAUTI, the majority of hospitals regularly used aseptic technique during catheter insertion (95%) and portable bladder ultrasound scanners (86.1%). Intermittent catheterization and catheter stop-orders were regularly used by 65.8 and 62.2% of hospitals. For CLABSI, all hospitals regularly used maximum sterile barrier precautions and chlorhexidine gluconate for insertion site antisepsis. Avoidance of the femoral site for central line insertions was regularly used by 65.9% of hospitals. Urinary catheters and central-lines impregnated with antibiotics or antiseptics were rarely used (≤ 5%). Selective decontamination strategies for preventing VAP were used in 84% of hospitals. With the exception of disposable thermometers (31.8%), all prevention practices to prevent CDI were regularly used by more than 80% of hospitals. Conclusions Most Dutch hospitals report regular use of recommended practices for preventing CLABSI and CDI. Several specific practices to prevent CAUTI and VAP were less frequently used, however, providing an opportunity for improvement.

Despite potential to capture rich contextual information, observation remains an underutilized data collection method. This paper provides a practical guide for using observation to understand complex issues in healthcare settings. Observation is a qualitative data collection method comprised of viewing and documenting phenomena in the usual environment. Drawing on our recent work using observation to better understand personal protective equipment use among healthcare personnel, we describe when to consider collecting data via observation, how to prepare and perform observation, and how to analyze resulting data. Observation data are documented in field notes that contain detailed information about setting, participants, and activity associated with the topic of interest. Field notes can be analyzed alone or triangulated with other types of data using theoretical or conceptual frameworks or by identifying themes. Observation is a valuable data collection method for health services researchers to identify key components involved in a topic of interest, a vital step in forming relevant questions, measuring appropriate variables, and designing effective interventions. Used with other methods or alone, observation yields the detailed data needed to address context-specific factors across a wide range of healthcare research topics and settings.

Abstract Background Antimicrobial stewardship to combat the spread of antibiotic-resistant bacteria has become a national priority. This project focuses on reducing inappropriate use of antimicrobials for asymptomatic bacteriuria (ASB), a very common condition that leads to antimicrobial overuse in acute and long-term care. We previously conducted a successful intervention, entitled “Kicking Catheter Associated Urinary Tract Infection (CAUTI): the No Knee-Jerk Antibiotics Campaign,” to decrease guideline-discordant ordering of urine cultures and antibiotics for ASB. The current objective is to facilitate implementation of a scalable version of the Kicking CAUTI campaign across four geographically diverse Veterans Health Administration facilities while assessing what aspects of an antimicrobial stewardship intervention are essential to success and sustainability. Methods This project uses an interrupted time series design with four control sites. The two main intervention tools are (1) an evidence-based algorithm that distills the guidelines into a streamlined clinical pathway and (2) case-based audit and feedback to train clinicians to use the algorithm. Our conceptual framework for the development and implementation of this intervention draws on May’s General Theory of Implementation. The intervention is directed at providers in acute and long-term care, and the goal is to reduce inappropriate screening for and treatment of ASB in all patients and residents, not just those with urinary catheters. The start-up for each facility consists of centrally-led phone calls with local site champions and baseline surveys. Case-based audit and feedback will begin at a given site after the start-up period and continue for 12 months, followed by a sustainability assessment. In addition to the clinical outcomes, we will explore the relationship between the dose of the intervention and clinical outcomes. Discussion This project moves from a proof-of-concept effectiveness study to implementation involving significantly more sites, and uses the General Theory of Implementation to embed the intervention into normal processes of care with usual care providers. Aspects of implementation that will be explored include dissemination, internal and external facilitation, and organizational partnerships. “Less is More” is the natural next step from our prior successful Kicking CAUTI intervention, and has the potential to improve patient care while advancing the science of implementation.

Importance: Thirty percent of Medicare accountable care organizations (ACOs) in the Shared Savings Program (SSP) have exited within five years of joining. Absent the potential for shared savings, exiting ACOs may choose to divest from costly resources needed to support population health, worsening clinical quality for beneficiaries aligned to these organizations., Objective: To examine the associations of SSP exit with clinical quality., Design Setting and Participants: Between 2019 and 2020 we conducted a retrospective cohort study with national Medicare claims from a 20% random sample of beneficiaries. We identified 1,713,237 beneficiaries aligned with an SSP ACO at some point between 2012 and 2016. We distinguished between those for whom the ACO to which they were aligned exited the SSP and those whose ACO stayed in the program. Comparing exiting ACOs with those who stayed in the SSP, we evaluated changes in the quality of care that a beneficiary received before and after the aligned ACO exited the SSP. We also examined whether findings associated with exit varied with respect to the number of years after exit., Exposures: SSP exit and the number of years after exit., Main Outcomes and Measures: Annual preventive care services receipt and hospital utilization., Results: The cohort of 1,713,237 individuals (mean [standard deviation] age at enrollment: 75.20 [7.96] years) included 998,511 (58.3%) female, 126,123 (7.4%) Black, and 1,482,823 white (86.6%) beneficiaries. SSP exit was associated with significantly lower rates of annual glycated hemoglobin testing (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.68 to 0.81), low-density lipoprotein cholesterol testing (OR, 0.86; 95% CI, 0.76 to 0.97), and all diabetes complication screening (OR, 0.90; 95% CI, 0.81 to 0.97), for beneficiaries with diabetes. The exit was not related to rates of hospital utilization, in terms of emergency department utilization and 30-day readmission after SSP exit. The associations with exit depended on the length of time since contracts end. For example, the baseline rate of annual glycated hemoglobin testing was 89.8% (95% CI, 89.5% to 90.1%) but fell to 86.9% (95% CI, 85.9% to 88.0%) and 86.8% (95% CI, 85.0% to 88.5%) in years 1 and 2 after exit, respectively, but it then rose to 91.9% (95% CI, 85.3% to 98.5%) in year 3., Conclusions and Relevance: In this cohort study of Medicare beneficiaries, SSP exit was associated with modest declines in clinical quality. These findings were timely given recent SSP changes that could accelerate program exit., Competing Interests: Conflict of Interest Disclosures: None reported.

A democratic deliberation panel of veterans providing insight into veteran perspectives on resource allocation and the Veterans Choice Act showed the importance and feasibility of engaging veterans in the policy-making process., Competing Interests: Author disclosures The authors report no actual or potential conflicts of interest with regard to this article., (Copyright © 2020 Frontline Medical Communications Inc., Parsippany, NJ, USA.)

: Background: Although certification by an accredited agency is often a practice prerequisite in health care, it is not required of vascular access specialists who insert peripherally inserted central catheters (PICCs). Whether certification is associated with differences in practice among inserters is unknown., Purpose: The purpose of this study was to gather information regarding whether certified and noncertified PICC inserters differ with respect to their practices and views about PICC use., Methods: We conducted a national survey of vascular access specialists, identifying certified PICC inserters as those who had received board certification from the Association for Vascular Access, the Infusion Nurses Society, or both. The 76-item survey asked about PICC policies and procedures at respondents' facilities, use of insertion technologies, device management, management of complications, perceptions about PICC use, and relationships with other health care providers. Additional data about respondents, including years in practice and primary practice settings, were also gathered. Bivariable comparisons were made using χ tests; two-sided α with P ≤ 0.05 was considered statistically significant., Results: Of the 1,450 respondents in the final sample, 1,007 (69%) said they were certified inserters and 443 (31%) said they were not. Significantly higher percentages of certified than noncertified inserters reported having practiced for five or more years (78% versus 54%) and having placed 1,000 or more PICCs (58% versus 32%). Significantly more certified than noncertified inserters also reported being the vascular access lead for their facility (56% versus 44%). Reported practice patterns for insertion, care, and management of PICCs varied based on certification status. Some evidence-based practices (such as the use of ultrasound to measure catheter-to-vein ratios) were more often reported by certified inserters, while others (such as the use of maximal sterile barriers during PICC insertion) were not. Asked about their perceptions of PICC use at their institution, certified inserters reported higher percentages of inappropriate insertion and removal than noncertified inserters., Conclusion: Certified PICC inserters appear to be a distinct group of vascular access specialists. A better understanding of how and why practices differ between certified and noncertified inserters is necessary to ensuring safer, high-quality patient care.