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OBJECTIVETo assess knowledge about infection prevention among nursing home personnel and identify gaps potentially addressable through a quality improvement collaborative.DESIGNBaseline knowledge assessment of catheter-associated urinary tract infection, asymptomatic bacteriuria, antimicrobial stewardship, and general infection prevention practices for healthcare-associated infections.SETTINGNursing homes across 14 states participating in the national “Agency for Healthcare Research and Quality Safety Program for Long-Term Care: Healthcare-Associated Infections/Catheter-Associated Urinary Tract Infection.”PARTICIPANTSLicensed (RNs, LPNs, APRNs, MDs) and unlicensed (clinical nursing assistants) healthcare personnel.METHODSEach facility aimed to obtain responses from at least 10 employees (5 licensed and 5 unlicensed). We assessed the percentage of correct responses.RESULTSA total of 184 (78%) of 236 participating facilities provided 1 response or more. Of the 1,626 respondents, 822 (50.6%) were licensed; 117 facilities (63.6%) were for-profit. While 99.1% of licensed personnel recognized the definition of asymptomatic bacteriuria, only 36.1% knew that pyuria could not distinguish a urinary tract infection from asymptomatic bacteriuria. Among unlicensed personnel, 99.6% knew to notify a nurse if a resident developed fever or confusion, but only 27.7% knew that cloudy, smelly urine should not routinely be cultured. Although 100% of respondents reported receiving training in hand hygiene, less than 30% knew how long to rub hands (28.5% licensed, 25.2% unlicensed) or the most effective agent to use (11.7% licensed, 10.6% unlicensed).CONCLUSIONSThis national assessment demonstrates an important need to enhance infection prevention knowledge among healthcare personnel working in nursing homes to improve resident safety and quality of care.Infect. Control Hosp. Epidemiol. 2016;1–6

Background Hospital-acquired infection, including catheter-associated urinary tract infection (CAUTI), is common. Although CAUTI is usually preventable, hospital units may struggle to reduce CAUTI rates. The CAUTI guide to patient safety (GPS) was developed to assess a unit's CAUTI prevention activities. Our aim was to qualitatively validate the GPS. Methods We interviewed participants from 2 units in each of 4 hospitals. Each unit's nurse manager completed the GPS and then discussed their answers with a trained research assistant. Semistructured interviews were conducted with unit nurses and physicians. We compared the nurse managers' answers to the unit physicians' and nurses' responses and assessed agreement. Results A total of 49 participants from 4 medical intensive care units and 4 medical-surgical units were interviewed. Nurse managers found the GPS helpful and complete. There was higher agreement between nurse managers and unit nurses than with physicians. Some questions generated more disagreement than others. Our findings suggest that the GPS is comprehensive and may be best used to stimulate discussions between stakeholders to address key issues. Conclusions Using the GPS to assess several stakeholders' views could allow a given unit to move its CAUTI prevention efforts forward in a more informed manner.

Patient-Centered Medical Home (PCMH) evaluations have primarily focused on primary care providers and not on the primary care team. This systematic literature review examined the extent to which access and care coordination measures in PCMH reflect the involvement of associate care providers (ACPs), which include registered and licensed practical nurses, nursing and medical assistants, clerks, pharmacists, social workers, and dietitians. Among 42 studies, few measures specified ACP roles or linked ACP care to outcomes. Increasing attention on team-based care emphasizes a vital need to reframe measures within a team context.

The aim of this study was to explain how the Polymerase Chain Reaction (PCR) technology was translated into professional practices to prevent and control vancomycin-resistant enterococci outbreaks via an actor-network, based on the integrated framework TRIP-ANT. A single case study was conducted in three purposefully selected sites implementing the PCR-VRE assay. The complete dataset comprised semi-structured interviews with 28 participants and a review of hospital and external documents. A content analysis was conducted. The authors' findings indicate the emergence of four main themes, including illustration of who was involved in the adoption process, attribution of roles and responsibilities, interaction/communication/ collaboration mechanisms, and changes in professional practices. Their findings also address five challenges that arose from each theme. The translation of PCR technology into professional practices relies on the enrolment of an organisational, clinical, managerial and financial support network, and on the evolution of practices, communications, and roles and responsibilities.

BACKGROUND: Catheter-associated urinary tract infection (UTI) is a common device-associated infection in hospitals. Both technical factors — appropriate catheter use, aseptic insertion, and proper maintenance — and socioadaptive factors, such as cultural and behavioral changes in hospital units, are important in preventing catheter-associated UTI. METHODS: The national Comprehensive Unit-based Safety Program, funded by the Agency for Healthcare Research and Quality, aimed to reduce catheter-associated UTI in intensive care units (ICUs) and non-ICUs. The main program features were dissemination of information to sponsor organizations and hospitals, data collection, and guidance on key technical and socioadaptive factors in the prevention of catheter-associated UTI. Data on catheter use and catheter-associated UTI rates were collected during three phases: baseline (3 months), implementation (2 months), and sustainability (12 months). Multilevel negative binomial models were used to assess changes in catheter use and catheter-associated UTI rates. RESULTS: Data were obtained from 926 units (59.7% were non-ICUs, and 40.3% were ICUs) in 603 hospitals in 32 states, the District of Columbia, and Puerto Rico. The unadjusted catheter-associated UTI rate decreased overall from 2.82 to 2.19 infections per 1000 catheter-days. In an adjusted analysis, catheter-associated UTI rates decreased from 2.40 to 2.05 infections per 1000 catheter-days (incidence rate ratio, 0.86; 95% confidence interval [CI], 0.76 to 0.96; P = 0.009). Among non-ICUs, catheter use decreased from 20.1% to 18.8% (incidence rate ratio, 0.93; 95% CI, 0.90 to 0.96; P

Aim/s To assess implementation of the Veterans Health Administration staffing methodology directive. Background In 2010 the Veterans Health Administration promulgated a staffing methodology directive for inpatient nursing units to address staffing and budget forecasting. Design A qualitative multi-case evaluation approach assessed staffing methodology implementation. Methods Semi-structured telephone interviews were conducted from March – June 2014 with Nurse Executives and their teams at 21 facilities. Interviews focused on the budgeting process, implementation experiences, use of data, leadership support, and training. An implementation score was created for each facility using a 4-point rating scale. The scores were used to select three facilities (low, medium and high implementation) for more detailed case studies. Results/findings After analysing interview summaries, the evaluation team developed a four domain scoring structure: (1) integration of staffing methodology into budget development; (2) implementation of the Directive elements; (3) engagement of leadership and staff; and (4) use of data to support the staffing methodology process. The high implementation facility had leadership understanding and endorsement of staffing methodology, confidence in and ability to work with data, and integration of staffing methodology results into the budgeting process. The low implementation facility reported poor leadership engagement and little understanding of data sources and interpretation. Conclusion Implementation varies widely across facilities. Implementing staffing methodology in facilities with complex and changing staffing needs requires substantial commitment at all organizational levels especially for facilities that have traditionally relied on historical levels to budget for staffing.

This study examined the effect of a walking intervention on step counts among patients with chronic back pain who report opioid use. Data were collected as part of a randomized trial to reduce back-pain-related disability. Participants (n = 118 usual care, 111 intervention) were Veterans receiving care within one healthcare system. Step counts were collected at baseline, 6 mo, and 12 mo via an uploading pedometer. Self-reported opioid use was collected by survey. More than 40% (n = 99) of participants reported opioid use at baseline. After adjustment, the predicted mean step count for baseline opioid users assigned to the intervention increased by more than 1,200 steps compared with a reduction of nearly 400 steps for those assigned to usual care (between-group difference = 1,625 steps, p = 0.004). Among nonopioid users, there was no change for those in the intervention (-16 steps) and an increase of about 660 steps for those assigned to usual care (between-group difference = 683 steps, p = 0.17). These data show that patients taking opioids may engage in walking to help manage their back pain. This finding emphasizes the importance of encouraging the use of alternative pain management strategies for these patients.

BACKGROUND Peripherally inserted central catheters (PICCs) are increasingly used in hospitalized patients. Yet, little is known about the vascular access nurses who often place them. METHODS We conducted a Web-based survey to assess vascular access nursing experience, practice, knowledge, and beliefs related to PICC insertion and care in 47 Michigan hospitals. RESULTS The response rate was 81% (172 received invitations, 140 completed the survey). More than half of all respondents (58%) reported placing PICCs for ≥5 years, and 23% had obtained dedicated vascular access certification. The most common reported indications for PICC insertion included intravenous antibiotics, difficult venous access, and chemotherapy. Many respondents (46%) reported placing a PICC in a patient receiving dialysis; however, 91% of these respondents reported receiving approval from nephrology prior to insertion. Almost all respondents (91%) used ultrasound to find a suitable vein for PICC insertion, and 76% used electrocardiography guidance to place PICCs. PICC occlusion was reported as the most frequently encountered complication, followed by device migration and deep vein thrombosis. Although 94% of respondents noted that their hospitals tracked the number of PICCs placed, only 40% reported tracking duration of PICC use. Relatedly, 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness. CONCLUSION This survey of vascular nursing experiences highlights opportunities to improve practices such as avoiding PICC use in dialysis, better tracking of PICC dwell times, and necessity. Hospitalists may use these data to inform clinical practice, appropriateness, and safety of PICCs in hospitalized patients. Journal of Hospital Medicine 2016;11:269–275. 2015 Society of Hospital Medicine

Catheter-associated urinary tract infection (CAUTI) surveillance is labor intensive, generally involving manual medical record review. We developed a prototype automated report through iterative design. Surveys and qualitative interviews were administered to key stakeholders to assess the report design. We found that different provider types expressed different needs regarding report content and format. Therefore, determining the primary audience for reporting data on CAUTI a priori is critical to developing useful reports, particularly as this process becomes standardized and automated.

This cohort study examines the fragmentation and dispersion of primary and specialist care along with care outcomes among patients with inflammatory bowel disease treated in the Veterans Health Administration health care system., Key Points Question Is a low level of continuity of care among patients with inflammatory bowel disease (IBD) associated with poor IBD-related outcomes? Findings In this cohort study of 20 079 US veterans with IBD receiving care in the Veterans Health Administration system, a low level of continuity of care was associated with a higher likelihood of flares that required corticosteroid treatment, hospitalization, and surgical intervention. Meaning This cohort study found that continuity of care varied in patients with IBD, even in an integrated system with systematically enhanced care coordination; this finding suggests the need to improve care coordination for patients with complex chronic conditions., Importance Health care fragmentation is associated with inefficiency and worse outcomes. Continuity of care (COC) models were developed to address fragmentation. Objective To examine COC and selected outcomes in US veterans with inflammatory bowel disease (IBD). Design, Setting, and Participants This retrospective cohort study used the Veterans Health Administration (VHA) Corporate Data Warehouse to identify veterans with IBD who received care in the VHA health care system between January 1, 2002, and December 31, 2014. Included patients were veterans with IBD who had a primary care physician and at least 4 outpatient visits with key physicians (gastroenterologist, primary care physician, and surgeon) within the first year after an index IBD encounter. Data were analyzed from November 2018 to May 2020. Exposures Care continuity was measured with the Bice-Boxerman COC index to define care density and dispersion within year 1 after the initial presentation. Main Outcomes and Measures A Cox proportional hazards regression model was used to quantify the association between a low level of COC in year 1 (defined as ≤0.25 on a 0 to 1 scale) and subsequent IBD-related outcomes in years 2 and 3 (outpatient flare, hospitalization, and surgical intervention). Results Among the 20 079 veterans with IBD who met the inclusion criteria, 18 632 were men (92.8%) and the median (interquartile range [IQR]) age was 59 (48-66) years. In the first year of follow-up, substantial variation in the dispersion of care was observed (median [IQR] COC, 0.24 [0.13-0.46]). In a Cox proportional hazards regression model, a low level of COC was associated with a higher likelihood of outpatient flares that required corticosteroids (adjusted hazard ratio [aHR], 1.11; 95% CI, 1.01-1.22), hospitalizations (aHR, 1.25; 95% CI, 1.06-1.47), and surgical interventions (aHR, 1.72; 95% CI, 1.43-2.07). Conclusions and Relevance Results of this cohort study showed a wide variation in dispersion of IBD care and an association between a lower level of COC and active IBD and worse outcomes. The findings suggest that investigating the barriers to COC in integrated systems that have invested in care coordination is key to not only better understanding COC but also identifying opportunities to improve care fragmentation.

Introduction: Survival and favorable clinical outcomes for in-hospital cardiac arrest (IHCA) are highly dependent on a skilled resuscitation team, prompt initiation of high quality CPR and defibrillation, and organizational structures to support resuscitation care. While nurses are generally involved in resuscitation efforts, the purpose of this study was to examine their specific roles and factors that affect their contributions during an IHCA response. Methods: We conducted a qualitative study at 9 hospitals participating in the AHA Get-With-The-Guidelines Resuscitation registry. Purposeful sampling was used to select hospitals that vary in terms of geography, academic status, and risk-standardized IHCA survival. Participants included nurses, physicians, respiratory therapists, pharmacists, quality improvement staff, hospital administrators, and other staff, yet discussion of the nursing function was prominent across all stakeholder groups. Qualitative thematic text analysis was used to identify the distinct types of nursing roles in relation to IHCA and how these roles were supported across sites. Results: We conducted semi-structured interviews with 158 individuals at 9 hospitals. Nurses were identified as an integral part of the IHCA response at all sites, with three major IHCA nursing roles identified: bedside first responder, rapid response or code team member, and leader. There were distinct differences across sites in support for nurses in these different roles with regard to educational training and competency, organizational engagement, and empowerment (Table). Conclusion: Nurses are a critical component of effective IHCA response and processes, including diverse roles as bedside first responders, code team members, and leadership for resuscitation care. Mentoring and empowering frontline nurses and ensuring that clinical competency and training needs for IHCA care specific for nurses is essential for resuscitation care.

Objectives The study of communication has evolved from diverse academic disciplines, yet those diverse fields are not well represented in theoretical frameworks that describe communication in health care, narrowing our ability to explain how communication affects patient safety. The purpose of this review article is to describe a conceptual framework of communication drawn from multiple academic disciplines and apply it to health care, specifically for examining communication between providers about the clinical care of their patients. Methods A seminal article in the field of communication that attempted to map the entire field of communication theory inspired our conceptual framework. We adapted these concepts, largely from the social science literature, to find alternative ways of conceptualizing communication and ways to enhance communication in health care. Results There are 8 theoretical traditions that informed our conceptual framework: rhetorical, phenomenological, semiotic, cybernetic, sociopsychological, sociocultural, critical, and pragmatic. We provide practical, clinical applications of our conceptual framework, encompassing the interpersonal nature of communication, relationship building and trust, hierarchical differences, and the role of technology in communication. In adopting our conceptual framework, we suggest that researchers and clinicians can choose from any combination of these 8 theoretical traditions to more fully describe and ultimately enhance communication-related phenomena. Conclusions Poor communication remains a stubborn problem in health care in part because of a narrow theoretical and definitional approach to resolving it. Our conceptual framework suggests ways to build relationships and trust, addresses hierarchical differences between communicators, and illuminates the role of technology in communication. It also importantly expands the definition of the value of communication beyond simple information exchange to include creation of new knowledge during communication through the development of shared understanding.

Background: To date, studies evaluating outcome improvements associated with participation in physician-led collaboratives have been limited by the absence of a contemporaneous control group. We examined post cardiac surgery pneumonia rates associated with participation in a statewide, quality improvement collaborative relative to a national physician reporting program. Methods and Results: We evaluated 911 754 coronary artery bypass operations (July 1, 2011, to June 30, 2017) performed across 1198 hospitals participating in a voluntary national physician reporting program (Society of Thoracic Surgeons [STS]), including 33 that participated in a Michigan-based collaborative (MI-Collaborative). Unlike STS hospitals not participating in the MI-Collaborative (i.e., STSnonMI) that solely received blinded reports, MI-Collaborative hospitals received a multi-faceted intervention starting November 2012 (quarterly in-person meetings showcasing unblinded data, webinars, site visits). Eighteen of the MI-Collaborative hospitals received additional support to implement recommended pneumonia prevention practices (“MI-CollaborativePlus”), whereas 15 did not (“MI-CollaborativeOnly”). We evaluated rates of postoperative pneumonia, adjusting for patient mix and hospital effects. Baseline patient characteristics were qualitatively similar between groups and time. During the pre-intervention period (Q3/2011 through Q3/2012), there was no statistically significant difference in the adjusted odds of pneumonia for STS hospitals participating in the MI-Collaborative compared to the STS non-MI hospitals. However, during the intervention period (Q4/2012 through Q2/2017), there was a significant 2% reduction per quarter in the adjusted odds of pneumonia for MI-Collaborative hospitals ( n =33) relative to the STS non-MI hospitals. There was a significant 3% per quarter reduction in the adjusted odds of pneumonia for the MI-Collaborative Only ( n =15) hospitals relative to the STS non-MI hospitals. Over the course of the overall study period, the STS non-MI hospitals had a 1.96% reduction in risk-adjusted pneumonia (pre- vs. intervention periods), which was less than the MI-Collaborative (3.23%, P =0.011). Over the same time period, the MI-Collaborative Plus ( n =18) reduced adjusted pneumonia rates by 10.29%, P =0.001. Conclusions: Participation in a physician-led collaborative was associated with significant reductions in pneumonia relative to a national quality reporting program. Interventions including collaborative learning may yield superior outcomes relative to solely using physician feedback reporting. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02068716.

Background Dissemination of evidence-based practices that can reduce morbidity and mortality is important to combat the growing opioid overdose crisis in the USA. Research and expert consensus support reducing high-dose opioid therapy, avoiding risky opioid-benzodiazepine combination therapy, and promoting multi-modal, collaborative models of pain care. Collaborative care interventions that support primary care providers have been effective in medication tapering. We developed a patient-centered Primary Care-Integrated Pain Support (PIPS) collaborative care clinical program based on effective components of previous collaborative care interventions. Implementation facilitation, a multi-faceted and dynamic strategy involving the provision of interactive problem-solving and support during implementation of a new program, is used to support key organizational staff throughout PIPS implementation. The primary aim of this study is to evaluate the effectiveness of the implementation facilitation strategy for implementing and sustaining PIPS in the Veterans Health Administration (VHA). The secondary aim is to examine the effect of the program on key patient-level clinical outcomes—transitioning to safer regimens and enhancing access to complementary and integrative health treatments. The tertiary aim is to determine the categorical costs and ultimate budget impact of PIPS implementation. Methods This multi-site study employs an interrupted time series, hybrid type III design to evaluate the effectiveness of implementation facilitation for a collaborative care clinical program—PIPS—in primary care clinics in three geographically diverse VHA health care systems (sites). Participants include pharmacists and allied staff involved in the delivery of clinical pain management services as well as patients. Eligible patients are prescribed either an outpatient opioid prescription greater than or equal to 90 mg morphine equivalent daily dose or a combination opioid-benzodiazepine regimen. They must also have an upcoming appointment in primary care. The Consolidated Framework for Implementation Research will guide the mixed methods work across the formative evaluation phases and informs the selection of activities included in implementation facilitation. The RE-AIM framework will be used to assess Reach, Effectiveness, Adoption, Implementation, and Maintenance of PIPS. Discussion This implementation study will provide important insight into the effectiveness of implementation facilitation to enhance uptake of a collaborative care program in primary care, which targets unsafe opioid prescribing practices. Electronic supplementary material The online version of this article (10.1186/s13012-018-0838-2) contains supplementary material, which is available to authorized users.

Team-based care models, including the patient-centered medical home (PCMH), are increasingly promoted to improve the delivery of primary care. However, evaluation measures are often reported at a clinic or primary care provider (PCP) level, creating challenges in describing and analyzing the use and impact of non-PCP clinician team members. Thus, we aimed to measure clinician-specific care delivery trends and determine whether trends were responsive to systemwide PCMH implementation.Interrupted time-series analysis of 57 million primary care encounters among 5 million veterans at 764 Veterans Health Administration primary care clinics from 2009 to 2013.Retrospective data identified patient encounters attributable to 12 types of clinicians, yielding an encounters-by-clinician metric. Negative binomial regression modeled the monthly clinic-level rates of encounters for each type of clinician, before and during PCMH implementation.Over 5 years, the percentage of encounters by non-PCP clinicians increased from 29% to 35%. Monthly encounter rates for nurses and social workers significantly increased by 0.5% and 1.3%, respectively, after the introduction of PCMH, whereas PCP encounter rates significantly decreased over time. Encounter trends for pharmacists, nutritionists, and behavioral health clinicians did not significantly change.This study demonstrated the feasibility of capturing care delivered by a full complement of team members using routinely collected data. Findings suggest that the proportions of care delivered by non-PCP clinicians were sensitive to a change in care delivery model. As team-based care models expand, availability and use of metrics that account for care by all team members are critical for inferring clinician-related effects on outcomes.

Background: In-hospital cardiac arrest (IHCA) is common, and outcomes vary substantially across US hospitals, but reasons for these differences are largely unknown. We set out to better understand how top-performing hospitals organize their resuscitation teams to achieve high survival rates for IHCA. Methods: We calculated risk-standardized IHCA survival to discharge rates across American Heart Association Get With The Guidelines–Resuscitation registry hospitals between 2012 and 2014. We identified geographically and academically diverse hospitals in the top, middle, and bottom quartiles of survival for IHCA and performed a qualitative study that included site visits with in-depth interviews of clinical and administrative staff at 9 hospitals. With the use of thematic analysis, data were analyzed to identify salient themes of perceived performance by informants. Results: Across 9 hospitals, we interviewed 158 individuals from multiple disciplines including physicians (17.1%), nurses (45.6%), other clinical staff (17.1%), and administration (20.3%). We identified 4 broad themes related to resuscitation teams: (1) team design, (2) team composition and roles, (3) communication and leadership during IHCA, and (4) training and education. Resuscitation teams at top-performing hospitals demonstrated the following features: dedicated or designated resuscitation teams; participation of diverse disciplines as team members during IHCA; clear roles and responsibilities of team members; better communication and leadership during IHCA; and in-depth mock codes. Conclusions: Resuscitation teams at hospitals with high IHCA survival differ from non–top-performing hospitals. Our findings suggest core elements of successful resuscitation teams that are associated with better outcomes and form the basis for future work to improve IHCA.

Background Diagnosis requires that clinicians communicate and share patient information in an efficient manner. Advances in electronic health records (EHRs) and health information technologies have created both challenges and opportunities for such communication. Methods We conducted a multi-method, focused ethnographic study of physicians on general medicine inpatient units in two teaching hospitals. Physician teams were observed during and after morning rounds to understand workflow, data sharing and communication during diagnosis. To validate findings, interviews and focus groups were conducted with physicians. Field notes and interview/focus group transcripts were reviewed and themes identified using content analysis. Results Existing communication technologies and EHR-based data sharing processes were perceived as barriers to diagnosis. In particular, reliance on paging systems and lack of face-to-face communication among clinicians created obstacles to sustained thinking and discussion of diagnostic decision-making. Further, the EHR created data overload and data fragmentation, making integration for diagnosis difficult. To improve diagnosis, physicians recommended replacing pagers with two-way communication devices, restructuring the EHR to facilitate access to key information and improving training on EHR systems. Conclusions As advances in health information technology evolve, challenges in the way clinicians share information during the diagnostic process will rise. To improve diagnosis, changes to both the technology and the way in which we use it may be necessary.

Key Points Question How has the proportion of US hospitals requiring receipt of annual influenza vaccination among health care personnel changed in recent years? Findings In this national survey study, which included responses from 1062 infection preventionists at both Veterans Affairs and non–Veterans Affairs hospitals between the 2013 and 2017 calendar years, required influenza vaccinations among health care personnel increased from 37.1% to 61.4%; this change was driven by increases in non–Veterans Affairs hospitals. Meaning Influenza vaccination mandates for health care personnel have increased in recent years, coinciding with concurrent increases in vaccination coverage among health care personnel., Importance Annual influenza vaccinations are currently recommended for all health care personnel (HCP) to limit the spread of influenza to those at high risk of developing serious complications from the virus. Vaccination coverage has been shown to be significantly greater among employers requiring and encouraging HCP to receive the annual influenza vaccination. Objectives To compare the proportion of respondent hospitals requiring HCP to receive annual influenza vaccination between 2013 and 2017 and to assess the degree to which these proportions differed between Veterans Affairs (VA) and non-VA hospitals. Design, Setting, and Participants This national survey study included responses from 1062 infection preventionists between 2013 and 2017 from nationally representative samples of all VA and non-VA hospitals in the United States. Data analysis was conducted from November 17, 2017, to March 26, 2018. Main Outcomes and Measures Survey response indicating hospital requirement for annual influenza vaccination of HCP. Results The overall response rate for the 2013 survey was 69.3% (non-VA, 70.6% [403 of 571]; VA, 63.5% [80 of 126]) and in 2017 was 59.1% (non-VA, 59.1% [530 of 897]; VA, 58.9% [73 of 124]). Among all responding hospitals, mandatory influenza vaccination requirements for HCP increased from 37.1% in 2013 to 61.4% in 2017 (difference, 24.3%; 95% CI, 18.4%-30.2%; P, This national survey study investigates changes in the proportion of hospitals requiring health care personnel to receive annual influenza vaccinations in 2013 and 2017 and compares the change among Veterans Affairs and non–Veterans Affairs hospitals.

BACKGROUND: Views and approaches of attendings and residents to diagnosis in teaching hospitals are poorly understood. Identifying barriers and facilitators to diagnosis may help inform interventions in these settings. METHODS: We conducted a focused ethnography of inpatient medicine teaching teams at two academic medical centers to understand what aspects might be targeted to improve diagnosis. Field notes regarding the diagnostic process (e.g., information gathering, integration and interpretation, working diagnosis) and work system (e.g., team members, organization, technology and tools, physical environment, tasks) were recorded. Following observations, focus groups and interviews were conducted to understand viewpoints, problems and solutions to improve diagnosis. RESULTS: Between January 2016 – May 2016, four teaching teams (4 attendings, 4 senior residents, 9 interns and 12 medical students) were observed for 168 hours. Observations of diagnosis as care was being delivered led to identification of four key themes: (a) diagnosis is a social phenomenon; (b) data necessary to make diagnoses are fragmented; (c) distractions interfere with the diagnostic process; and (d) time pressures impede diagnostic decision-making. These observations suggest that interventions tailored to the academic setting such as team-based discussions of diagnostic workups, scheduling diagnostic time-outs during the day and strategies to “protect” learners from interruptions might prove useful in improving the process of diagnosis. Future studies that implement these ideas (either alone or within a multi-modal intervention) appear necessary. CONCLUSION: Diagnosis in teaching hospitals is a unique process in need of improvement. Contextual insights gained from this ethnography may be used to inform future interventions.

Chronic pain is widely prevalent among Veterans and can have serious negative consequences for functional status and quality of life among other domains. The Veterans Health Administration (VHA) convened a state-of-the-art (SOTA) conference to develop research priorities for advancing the science and clinical practice of non-pharmacological management of chronic musculoskeletal pain. In this perspective article, we present the methods and consensus recommendations for research priorities emanating from the SOTA. In the months leading up to the SOTA, a core group of researchers defined four areas of focus: psychological/behavioral therapies; exercise/movement therapies; manual therapies; and models for delivering multi-modal pain care and divided into workgroups. Each workgroup, in their respective areas of focus, identified seminal studies capturing the state of the evidence. Herein, we present consensus recommendations ranging from efficacy to effectiveness to implementation/dissemination research depending on the state of the evidence as assessed by participants, including commentary on common elements across workgroups and future areas of innovation in study design, measurement, and outcome ascertainment.

OBJECTIVES: To understand how physicians from various specialties perceive coordination of care when managing peri-procedural anticoagulation. STUDY DESIGN: Cross-sectional survey of cardiologists, gastroenterologists, and primary care physicians (PCPs) in an integrated health system (N=251). METHODS: The survey began with a vignette of a patient with atrial fibrillation co-managed by his PCP, cardiologist, and an anticoagulation clinic who must hold warfarin for a colonoscopy. Respondents’ experiences and opinions around responsibilities and institutional support for managing peri-procedural anticoagulation were elicited using multiple choice questions. We examined differences in responses across specialties using chi-square analysis. RESULTS: The response rate was 51% (n=127). 52% were PCPs, 28% cardiologists, and 21% gastroenterologists. Nearly half (47.2%) of respondents believed that the cardiologist should be primarily responsible for managing peri-procedural anticoagulation, while fewer identified the PCP (25.2%), anticoagulation clinic (21.3%), or gastroenterologist (6.3%; p=0.09). Respondents across specialties had significantly different approaches to deciding how to manage the clinical case presented (p

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.

BackgroundDespite decades of research and interventions, poor communication between physicians and nurses continues to be a primary contributor to adverse events in the hospital setting and a major challenge to improving patient safety. The lack of progress suggests that it is time to consider alternative approaches with greater potential to identify and improve communication than those used to date. We conducted a formative evaluation to assess the feasibility, acceptability and utility of using video reflexive ethnography (VRE) to examine, and potentially improve, communication between nurses and physicians.MethodsWe begin with a brief description of the institutional review boardapproval process and recruitment activities, then explain how we conducted the formative evaluation by describing (1) the VRE process itself; (2) our assessment of the exposure to the VRE process; and (3) challenges encountered and lessons learnt as a result of the process, along with suggestions for change.ResultsOur formative evaluation demonstrates that it is feasible and acceptable to video-record communication between physicians and nurses during patient care rounds across many units at a large, academic medical centre. The lessons that we learnt helped to identify procedural changes for future projects. We also discuss the broader application of this methodology as a possible strategy for improving other important quality and safety practices in healthcare settings.ConclusionsThe VRE process did generate increased reflection in both nurse and physician participants. Moreover, VRE has utility in assessing communication and, based on the comments of our participants, can serve as an intervention to possibly improve communication, with implications for patient safety.

Use of peripherally inserted central catheters (PICCs) has grown substantially in recent years. Increasing use has led to the realization that PICCs are associated with important complications, including thrombosis and infection. Moreover, some PICCs may not be placed for clinically valid reasons. Defining appropriate indications for insertion, maintenance, and care of PICCs is thus important for patient safety. An international panel was convened that applied the RAND/UCLA Appropriateness Method to develop criteria for use of PICCs. After systematic reviews of the literature, scenarios related to PICC use, care, and maintenance were developed according to patient population (for example, general hospitalized, critically ill, cancer, kidney disease), indication for insertion (infusion of peripherally compatible infusates vs. vesicants), and duration of use (≤5 days, 6 to 14 days, 15 to 30 days, or ≥31 days). Within each scenario, appropriateness of PICC use was compared with that of other venous access devices. After review of 665 scenarios, 253 (38%) were rated as appropriate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappropriate. For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer days. Midline catheters and ultrasonography-guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days. In critically ill patients, nontunneled central venous catheters were preferred over PICCs when 14 or fewer days of use were likely. In patients with cancer, PICCs were rated as appropriate for irritant or vesicant infusion, regardless of duration. The panel of experts used a validated method to develop appropriate indications for PICC use across patient populations. These criteria can be used to improve care, inform quality improvement efforts, and advance the safety of medical patients.

While type 2 diabetes mellitus (DM) is a common condition of midlife women, few studies have examined its influence on the symptom features of menopause. To explore this relationship, we conducted a study of symptom patterns of diabetic patients using a random sample of female veterans receiving care in the Veterans Affairs Healthcare system.A cross-sectional comparison was conducted with three groups of postmenopausal respondents (ages 45-60 years) to a mailed national survey who also consented to clinical data access: no diabetes (n=90), diabetes with better glucose control (hemoglobin A1c [HbA1c]≤7%, n=135) and diabetes with worse glucose control (HbA1c7%, n=102).Respondents, on average, were obese (body mass index: 33.9±0.4 kg/m(2)), 11.30±0.2 years postmenopause, with more than one chronic illness. Despite higher body mass index and increased comorbidities in women with diabetes compared with nondiabetic women, measures of mental health (anxiety, depressed mood, stress) were similar across groups. The pattern of menopause symptoms did not differ by group. Muscle aches/joint pain was the most prevalent symptom (78.6%), followed by vasomotor symptoms (74.4%). Respondents with elevated HbA1c demonstrated higher total menopausal symptom severity scores (DM-HbA1c7: 15.4±0.8 vs. DM-HbA1c≤7%: 12.2±0.8 vs. No diabetes: 12.3±0.8; p=0.006) than the other two groups.In postmenopausal female veterans with diabetes, glucose control is associated with the severity of those symptoms commonly attributed to menopause. Joint pain is an important part of the postmenopausal symptom complex in this population.

Interventions to reduce urinary catheter use involve lists of "appropriate" indications developed from limited evidence without substantial multidisciplinary input. Implementing these lists, however, is challenging given broad interpretation of indications, such as "critical illness." To refine criteria for appropriate catheter use-defined as use in which benefits outweigh risks-the RAND/UCLA Appropriateness Method was applied. After reviewing the literature, a 15-member multidisciplinary panel of physicians, nurses, and specialists in infection prevention rated scenarios for catheter use as appropriate, inappropriate, or of uncertain appropriateness by using a standardized, multiround rating process. The appropriateness of Foley catheters, intermittent straight catheters (ISCs), and external condom catheters for hospitalized adults on medical services was assessed in 299 scenarios, including urinary retention, incontinence, wounds, urine volume measurement, urine sample collection, and comfort. The scenarios included patient-specific issues, such as difficulty turning and catheter placement challenges. The panel rated 105 Foley scenarios (43 appropriate, 48 inappropriate, 14 uncertain), 97 ISC scenarios (15 appropriate, 66 inappropriate, 16 uncertain), and 97 external catheter scenarios (30 appropriate, 51 inappropriate, 16 uncertain). The refined criteria clarify that Foley catheters are appropriate for measuring and collecting urine only when fluid status or urine cannot be assessed by other means; specify that patients in the intensive care unit (ICU) need specific medical indications for catheters because ICU location alone is not an appropriate indication; and recognize that Foley and external catheters may be pragmatically appropriate to manage urinary incontinence in select patients. These new appropriateness criteria can inform large-scale collaborative and bedside efforts to reduce inappropriate urinary catheter use.

Background Numerous initiatives have focused on reducing device-associated infections, contributing to an overall decrease in infections nationwide. To better understand factors associated with this decline, we assessed the use of key practices to prevent device-associated infections by US acute care hospitals from 2005 to 2013. Methods We mailed surveys to infection preventionists at a national random sample of ∼600 US acute care hospitals in 2005, 2009 and 2013. Our survey asked about the use of practices to prevent the 3 most common device-associated infections: central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infection (CAUTI). Using sample weights, we estimated the per cent of hospitals reporting regular use (a score of 4 or 5 on a scale from 1 (never use) to 5 (always use)) of prevention practices from 2005 to 2013. Results The response rate was about 70% in all 3 periods. Use of most recommended prevention practices increased significantly over time. Among those showing the greatest increase were use of an antimicrobial dressing for preventing CLABSI (25–78%, p

Preventing healthcare-associated infection (HAI) is a key contributor to enhancing resident safety in nursing homes. In 2013, the U.S. Department of Health and Human Services approved a plan to enhance resident safety by reducing HAIs in nursing homes, with particular emphasis on reducing indwelling catheter use and catheter-associated urinary tract infection (CAUTI). Lessons learned from a recent multimodal Targeted Infection Prevention program in a group of nursing homes as well as a national initiative to prevent CAUTI in over 950 acute care hospitals called "On the CUSP: STOP CAUTI" will now be implemented in nearly 500 nursing homes in all 50 states through a project funded by the Agency for Healthcare Research and Quality (AHRQ). This "AHRQ Safety Program in Long-Term Care: HAIs/CAUTI" will emphasize professional development in catheter utilization, catheter care and maintenance, and antimicrobial stewardship as well as promoting patient safety culture, team building, and leadership engagement. We anticipate that an approach integrating technical and socio-adaptive principles will serve as a model for future initiatives to reduce other infections, multidrug resistant organisms, and noninfectious adverse events among nursing home residents.

Catheter-associated urinary tract infection (UTI) in nursing home residents is a common cause of sepsis, hospital admission, and antimicrobial use leading to colonization with multidrug-resistant organisms.To develop, implement, and evaluate an intervention to reduce catheter-associated UTI.A large-scale prospective implementation project was conducted in community-based nursing homes participating in the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. Nursing homes across 48 states, Washington DC, and Puerto Rico participated. Implementation of the project was conducted between March 1, 2014, and August 31, 2016.The project was implemented over 12-month cohorts and included a technical bundle: catheter removal, aseptic insertion, using regular assessments, training for catheter care, and incontinence care planning, as well as a socioadaptive bundle emphasizing leadership, resident and family engagement, and effective communication.Urinary catheter use and catheter-associated UTI rates using National Healthcare Safety Network definitions were collected. Facility-level urine culture order rates were also obtained. Random-effects negative binomial regression models were used to examine changes in catheter-associated UTI, catheter utilization, and urine cultures and adjusted for covariates including ownership, bed size, provision of subacute care, 5-star rating, presence of an infection control committee, and an infection preventionist.In 4 cohorts over 30 months, 568 community-based nursing homes were recruited; 404 met inclusion criteria for analysis. The unadjusted catheter-associated UTI rates decreased from 6.78 to 2.63 infections per 1000 catheter-days. With use of the regression model and adjustment for facility characteristics, the rates decreased from 6.42 to 3.33 (incidence rate ratio [IRR], 0.46; 95% CI, 0.36-0.58; P .001). Catheter utilization was 4.5% at baseline and 4.9% at the end of the project. Catheter utilization remained unchanged (4.50 at baseline, 4.45 at conclusion of project; IRR, 0.95; 95% CI, 0.88-1.03; P = .26) in adjusted analyses. The number of urine cultures ordered for all residents decreased from 3.49 per 1000 resident-days to 3.08 per 1000 resident-days. Similarly, after adjustment, the rates were shown to decrease from 3.52 to 3.09 (IRR, 0.85; 95% CI, 0.77-0.94; P = .001).In a large-scale, national implementation project involving community-based nursing homes, combined technical and socioadaptive catheter-associated UTI prevention interventions successfully reduced the incidence of catheter-associated UTIs.

Background Numerous evidence-based practices for preventing device-associated infections are available, yet the extent to which these practices are regularly used in acute care hospitals across different countries has not been compared, to our knowledge. Methods Data from hospital surveys conducted in Japan, the United States, and Thailand in 2012, 2013, and 2014, respectively, were evaluated to determine the use of recommended practices to prevent central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infection (CAUTI). The outcomes were the percentage of hospitals reporting regular use (a score of 4 or 5 on a scale from 1 [never use] to 5 [always use]) of each practice across countries and identified hospital characteristics associated with the use of selected practices in each country. Results Survey response rates were 71% in Japan and the United States and 87% in Thailand. A majority of hospitals in Japan (76.6%), Thailand (63.2%), and the United States (97.8%) used maximum barrier precautions for preventing CLABSI and semirecumbent positioning to prevent VAP (66.2% for Japan, 86.7% for Thailand, and 98.7% for the United States). Nearly all hospitals (>90%) in Thailand and the United States reported monitoring CLABSI, VAP, and CAUTI rates, whereas in Japan only CLABSI rates were monitored by a majority of hospitals. Regular use of CAUTI prevention practices was variable across the 3 countries, with only a few practices adopted by >50% of hospitals. Conclusions A majority of hospitals in Japan, Thailand, and the United States have adopted certain practices to prevent CLABSI and VAP. Opportunities for targeting prevention activities and reducing device-associated infection risk in hospitals exist across all 3 countries.

Importance Recommendations for chronic pain treatment emphasize multimodal approaches, including nonpharmacologic interventions to enhance self-management. Cognitive behavioral therapy (CBT) is an evidence-based treatment that facilitates management of chronic pain and improves outcomes, but access barriers persist. Cognitive behavioral therapy delivery assisted by health technology can obviate the need for in-person visits, but the effectiveness of this alternative to standard therapy is unknown. The Cooperative Pain Education and Self-management (COPES) trial was a randomized, noninferiority trial comparing IVR-CBT to in-person CBT for patients with chronic back pain. Objective To assess the efficacy of interactive voice response–based CBT (IVR-CBT) relative to in-person CBT for chronic back pain. Design, Setting, and Participants We conducted a noninferiority randomized trial in 1 Department of Veterans Affairs (VA) health care system. A total of 125 patients with chronic back pain were equally allocated to IVR-CBT (n = 62) or in-person CBT (n = 63). Interventions Patients treated with IVR-CBT received a self-help manual and weekly prerecorded therapist feedback based on their IVR-reported activity, coping skill practice, and pain outcomes. In-person CBT included weekly, individual CBT sessions with a therapist. Participants in both conditions received IVR monitoring of pain, sleep, activity levels, and pain coping skill practice during treatment. Main Outcomes and Measures The primary outcome was change from baseline to 3 months in unblinded patient report of average pain intensity measured by the Numeric Rating Scale (NRS). Secondary outcomes included changes in pain-related interference, physical and emotional functioning, sleep quality, and quality of life at 3, 6, and 9 months. We also examined treatment retention. Results Of the 125 patients (97 men, 28 women; mean [SD] age, 57.9 [11.6] years), the adjusted average reduction in NRS with IVR-CBT (−0.77) was similar to in-person CBT (−0.84), with the 95% CI for the difference between groups (−0.67 to 0.80) falling below the prespecified noninferiority margin of 1 indicating IVR-CBT is noninferior. Fifty-four patients randomized to IVR-CBT and 50 randomized to in-person CBT were included in the analysis of the primary outcome. Statistically significant improvements in physical functioning, sleep quality, and physical quality of life at 3 months relative to baseline occurred in both treatments, with no advantage for either treatment. Treatment dropout was lower in IVR-CBT with patients completing on average 2.3 (95% CI, 1.0-3.6) more sessions. Conclusions and Relevance IVR-CBT is a low-burden alternative that can increase access to CBT for chronic pain and shows promise as a nonpharmacologic treatment option for chronic pain, with outcomes that are not inferior to in-person CBT. Trial Registration clinicaltrials.gov Identifier:NCT01025752

In 2014 the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) implemented a Virtual Breakthrough Series (VBTS) collaborative to help VHA facilities prevent hospital-acquired conditions: catheter-associated urinary tract infection (CAUTI) and hospital-acquired pressure ulcers (HAPUs).During the prework phase, participating facilities assembled a multidisciplinary team, assessed their current system for CAUTI or HAPU prevention, and examined baseline data to set improvement aims. The action phase consisted of educational conference calls, coaching, and monthly team reports. Learning was conducted via phone, web-based options, and e-mail. The CAUTI bundle focused on four key principles: (1) avoidance of indwelling urinary catheters, (2) proper insertion technique, (3) proper catheter maintenance, and (4) timely removal of the indwelling catheter. The HAPU bundle focused on assessment and inspection, pressure-relieving surfaces, turning and repositioning, incontinence management, and nutrition/hydration assessment and intervention.For the 18 participating units, the mean aggregated CAUTI rate decreased from 2.37 during the prework phase to 1.06 per 1,000 catheter-days during the action (implementation) phase (p0.001); the rate did not change for CAUTI nonparticipating sites. HAPU data were available only for 21 of the 31 participating units, whose mean aggregated HAPU rate decreased from 1.80 to 0.99 from prework to continuous improvement (p0.001). Staff education and documentation improvement were the most frequently implemented changes.This project helped improve CAUTI and HAPU rates in the VHA and presents a promising model for implementing a virtual model for improvement.

Preventing catheter-associated urinary tract infection (CAUTI) remains a significant challenge for US hospitals. The "On the CUSP: Stop CAUTI" initiative represents the single largest national effort (involving >950 hospitals) to mitigate urinary catheter risk. The program brings together key organizations to assist state hospital associations and hospitals by providing education and coaching support, addressing both the technical aspects of preventing CAUTI and CAUTI-specific socio-adaptive challenges. At the local level, engaging health care workers, from physicians and nurses to other ancillary services, is critical. This includes (1) making the importance of addressing CAUTI stakeholder specific, (2) ensuring support from leaders of essential disciplines, (3) underscoring the importance of the collaborative nature of CAUTI prevention, and (4) identifying champions within the organization to lead and be accountable for the work. Sustainability is ensured by integrating the process into the health care worker's daily routine activities.

Clinical performance measurement has been a key element of efforts to transform the Veterans Health Administration (VHA). However, there are a number of signs that current performance measurement systems used within and outside the VHA may be reaching the point of maximum benefit to care and in some settings, may be resulting in negative consequences to care, including overtreatment and diminished attention to patient needs and preferences. Our research group has been involved in a long-standing partnership with the office responsible for clinical performance measurement in the VHA to understand and develop potential strategies to mitigate the unintended consequences of measurement.Our aim was to understand how the implementation of diabetes performance measures (PMs) influences management actions and day-to-day clinical practice.This is a mixed methods study design based on quantitative administrative data to select study facilities and quantitative data from semi-structured interviews.Sixty-two network-level and facility-level executives, managers, front-line providers and staff participated in the study.Qualitative content analyses were guided by a team-based consensus approach using verbatim interview transcripts. A published interpretive motivation theory framework is used to describe potential contributions of local implementation strategies to unintended consequences of PMs.Implementation strategies used by management affect providers' response to PMs, which in turn potentially undermines provision of high-quality patient-centered care. These include: 1) feedback reports to providers that are dissociated from a realistic capability to address performance gaps; 2) evaluative criteria set by managers that are at odds with patient-centered care; and 3) pressure created by managers' narrow focus on gaps in PMs that is viewed as more punitive than motivating.Next steps include working with VHA leaders to develop and test implementation approaches to help ensure that the next generation of PMs motivate truly patient-centered care and are clinically meaningful.

Implementing polymerase chain reaction (PCR) technology in the context of infection prevention and control (IPC) at Centre Hospitalier Universitaire (CHU) de Quebec necessitated organisational change involving new infection prevention and control (IPC) procedures, the organisation of hospital services and attribution of new roles within a network of actors, at the macro, meso and micro levels. Understanding how the adoption of IPC technology can transform healthcare practices and outcomes for patients will remain a challenge as long as the process lacks a theoretical basis. This paper discusses a conceptual framework that will make it possible to understand the dynamics involved in implementing practice change. To identify the outcomes of such a process, both from the point of view of the nursing staff and that of patients, an integrated model was developed based on the Translating Research Into Practice (TRIP) model and on the Actor-Network Theory (ANT). The TRIP-ANT model provides a basis for exploring the complexity of implementing technology in the context of IPC and illustrates the dynamic nature of healthcare organisation in the real world. It identifies how new technology integration can translate into different responses to change and into the practices of a network of actors involved directly or indirectly in the new intra- and inter-organisational processes surrounding the handling of IPC practices. Furthermore, this model could also be applied to other innovations in healthcare organisations.

SummaryBackground Despite growing use, peripherally inserted central catheters (PICCs) are associated with risk of deep vein thrombosis (DVT). We designed a study to determine patient, provider and device factors associated with this outcome. Methods This was a retrospective cohort study of adults who underwent PICC placement between 1 June 2009 to 30 June 2012. Symptomatic PICC-associated DVT was confirmed by ultrasound. Because PICCs are also recognized risk factors for lower-extremity DVT, lower-extremity DVT occurring while the PICC was in situ was included. Multivariable logistic and Cox-proportional hazards regression models were fit to examine the association between covariates specified a priori and PICC-DVT. Odds ratios (ORs) and hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) were generated. Results Of 966 unique PICC placements, 33 patients developed symptomatic PICC-associated DVT and 9 developed lower-extremity DVT, accounting for 42 thrombotic events. On bivariate analysis, recent diagnosis of cancer, interventional radiology placement, chemotherapy administration, number of lumens and PICC-gauge were associated with PICC-DVT. Following multivariable adjustment, recent cancer diagnosis (OR 1.95 [95% CI 1.01–3.76]) and PICC gauge (HR 2.21 [95%CI 1.04–4.70] and HR 3.56 [95%CI 1.31–9.66] for 5-Fr and 6-Fr PICCs, respectively) remained associated with thrombosis. Conclusions Recent diagnosis of cancer and PICC gauge are associated with PICC-DVT. These findings have important clinical ramifications and suggest that placement of large gauge PICCs or PICCs in patients with cancer may provoke thrombosis. Improved policies and procedural oversights in these areas appear necessary to prevent PICC-DVT.

In 2010, the Veterans Health Administration (VHA) began implementation of its medical home, Patient Aligned Care Teams (PACT), in 900 primary care clinics nationwide, with 120 located in academically affiliated medical centers. The literature on Patient-Centered Medical Home (PCMH) implementation has focused mainly on small, nonacademic practices.To understand the experiences of primary care leadership, physicians and staff during early PACT implementation in a VHA academically affiliated primary care clinic and provide insights to guide future PCMH implementation.We conducted a qualitative case study during early PACT implementation.Primary care clinical leadership, primary care providers, residents, and staff.Between February 2011 and March 2012, we conducted 22 semi-structured interviews, purposively sampling participants by clinic role, and convenience sampling within role. We also conducted observations of 30 nurse case manager staff meetings, and collected data on growth in the number of patients, staff, and physicians. We used a template organizing approach to data analysis, using select constructs from the Consolidated Framework for Implementation Research (CFIR).Establishing foundational requirements was an essential first step in implementing the PACT model, with teamlets able to do practice redesign work. Short-staffing undermined development of teamlet working relationships. Lack of co-location of teamlet members in clinic and difficulty communicating with residents when they were off-site hampered communication. Opportunities to educate and reinforce PACT principles were constrained by the limited clinic hours of part-time primary care providers and residents, and delays in teamlet formation.Large academic medical centers face special challenges in implementing the medical home model. In an era of increasing emphasis on patient-centered care, our findings will inform efforts to both improve patient care and train clinicians to move from physician-centric to multidisciplinary care delivery.

Obesity is a significant health problem among Vet- erans who receive care from the Department of Veterans Affairs, as it is for so many other Americans. Veterans from Operation Enduring Freedom (OEF) and Operation Iraqi Free- dom (OIF) experience a myriad of chronic conditions, which can make it difficult to maintain a physically active lifestyle. This pilot study tested the feasibility and user satisfaction with three low-cost, home-based diet and exercise programs, as well as point-of-decision prompts among these Veterans. The three programs target mechanisms that have been shown to improve healthy behavior change, including (1) online mediated social support, (2) objective monitoring of physical activity, and (3) structured high-intensity workouts. This was a randomized crossover trial; each participant used two of the three pro- grams, and all used the point-of-decision prompts. Our qualita- tive results identified five overall themes related to social support, objective monitoring, structured activity, awareness and understanding, and the point-of-decision prompts. In gen- eral, participants were satisfied with and lost weight with each of the interventions. This study demonstrated that these low- cost interventions could be successful with the OIF/OEF Vet- eran population. A larger and longer study is planned to further investigate the effectiveness of these interventions.

Vascular access specialists are increasingly responsible for insertion and care of peripherally inserted central catheters in the United States. Despite proliferation of the specialty, little is known about the training, practice patterns, and experiences of these clinicians. In partnership with a vascular access and an infusion nursing organization, a Web-based survey of 1698 clinicians was conducted. Substantial variation in practices related to insertion, use of technology, dressing and flushing, and management of complications was observed. Some reported practices were inconsistent with available evidence-based recommendations. Therefore, opportunities to improve patient care and further explore reasons driving such variation exist and should be explored.

Background CDC provides guidelines for using contact precautions (CP) when caring for patients with antibiotic-resistant bacteria or Clostridium difficile. However, HCP frequently report discomfort, difficulty of use, and interrupted workflow with CP. Modifying CP guidelines to balance these issues requires testing to assess benefits and maintenance of safe practices. A promising approach using a “PPE Free Zone” strategy within rooms of patients in CP has not been well-studied. Methods The PPE Free Zone comprised a 3–6 foot area inside door thresholds of CP patient rooms denoted by red tape placed on the floor. Within the zone, HCP were not required to don PPE. HCP were considered compliant if they performed hand hygiene (HH) and donned appropriate PPE before crossing the zone. Observers at 6 acute care facilities (ACF) were trained on observing HCP HH and use of PPE with CP. Observations were made before and after implementation of a PPE Free Zone. Intervention ACF conducted observations on 8 intervention units and 6 nonintervention units. Models of overall compliance and entry HH compliance were constructed using a generalized linear-mixed effects model with a logistic link function. Pre-intervention observations from all 6 ACF and intervention phase observations from the 3 intervention ACF were used in models. Results We observed 4,510 room entries. HH adherence declined over time in both intervention and control units but declined less among intervention units from pre to post intervention (β: 0.71, P = 0.007, Figure 1). Stratified by precautions type, the effect of the PPE Free Zone on HH was only significant for rooms in enteric precautions (P < 0.001). Compliance with PPE use was not significantly different pre- versus postintervention (P = 0.133). When surveyed, HCP had positive views of the PPE Free Zone: 65% (n = 172) agreed or strongly agreed the zone facilitates communication with patients, permits checking on patients more frequently, and saves time [n = 169] (Figure 2). Conclusion Although HCP viewed the zone positively and it had a significant effect on HH in enteric precautions rooms, the zone did not improve PPE compliance. Future interventions in the ACF setting should consider the complex sociotechnical system factors influencing behavior change. Disclosures All authors: No reported disclosures.

BACKGROUND In November 2019, Centers for Medicare & Medicaid Services (CMS) will require skilled nursing facilities (SNFs) to have an infection preventionist (IP) with “specialized training.” Meeting this requirement may prove difficult for many SNFs due to staff turnover, lack of resources and increasing patient acuity. The purpose of this study was to better understand SNF readiness for meeting the challenges ahead. METHODS In 2018, data were collected through a survey administered to 12 SNFs. These SNFs participated in the pilot phase of larger project designed to reduce healthcare-associated infections (HAIs) by enhancing relationships between SNFs and hospitals. The survey included facility-based questions of services provided and their current infection prevention program; IP experience and education; and communication between SNFs and hospitals. Following the survey, qualitative data were collected through semi-structured interviews at 4 SNFs and analyzed using a descriptive approach. RESULTS The 12 SNFs varied in size and services provided. Over half of the 12 IPs had “five years or less” experience in infection prevention. All of the IPs had other responsibilities such as staff education/development, occupational health, or assistant director of nursing. Ten months into the 12-month pilot year, 7 of the 12 IPs had left their IP position. The SNFs remained enrolled in the project, with the project team engaging the SNF IP in their new role and acquainting them to project-related resources. Our qualitative analysis revealed that these meetings met a critical need for new IPs. One of the interviewees noted that the “mentorship” offered by the project was vital to continue existing IP efforts at the SNF. CONCLUSIONS Limited IP experience and turnover will pose a significant challenge for SNFs in trying to meet CMS mandates. Strategies should encourage relationships with experienced IPs to assist SNFs in training and retaining IPs.

The use of peripherally inserted central catheters (PICCs) has increased substantially within hospitals during the past several years. Yet, the prevalence and practices of designated nurse PICC teams (i.e., specially trained nurses who are responsible for PICC insertions at a hospital) are unknown. We, therefore, identified the prevalence of and factors associated with having a designated nurse PICC team among U.S. acute care hospitals.We conducted a survey of infection preventionists at a random sample of U.S. hospitals in May 2013, which asked about personnel who insert PICCs and the use of practices to prevent device-associated infections, including central line-associated bloodstream infection. We compared practice use between hospitals that have a designated nurse PICC team versus those that do not.Survey response rate was 70% (403/575). According to the respondents, nurse PICC teams inserted PICCs in more than 60% of U.S. hospitals in 2013. Moreover, certain practices to prevent central line-associated bloodstream infection, including maximum sterile barrier precautions (93% versus 88%, P = 0.06), chlorhexidine gluconate for insertion site antisepsis (96% versus 87%, P = .003) and facility-wide insertion checklists (95% versus 87%, P = 0.02) were regularly used by a higher percentage of hospitals with nurse PICC teams compared with those without.These data suggest that nurse PICC teams play an integral role in PICC use at many hospitals and that use of such teams may promote key practices to prevent complications. Better understanding of the role, composition, and practice of such teams is an important area for future study.

BACKGROUND Although hospitalists may improve efficiency and quality of inpatient care, their effect on healthcare-worker communication and education has been less well-studied. OBJECTIVE To test various approaches to improving healthcare-worker communication and learner education within the context of a newly designed academic hospital medicine program. DESIGN Before-and-after design with concurrent control group. SETTING A Midwestern Veterans Affairs medical center. INTERVENTION Multimodal systems redesign of 1 of 4 medical teams (Gold team) that included clinical modifications (change in rounding structure, with inclusion of nurses, a Clinical Care Coordinator, and a pharmacist) and educational interventions (providing explicit expectations of learners and providing a reading list for both learners and attending physicians). MEASUREMENTS Number of admissions, length of stay, readmissions, house officer and medical student ratings of attendings' teaching, medical student internal medicine National Board of Medical Examiners Subject Examination (“shelf” exam) scores, and clinical staff surveys. RESULTS Length of stay was reduced by about 0.3 days on all teams after the initiative began (P = 0.004), with no significant differences between Gold and non-Gold teams. The majority of physicians (83%) and nurses (68%) felt that including nurses during rounds improved healthcare-worker communication; significantly more nurses were satisfied with communication with the Gold team than with the other teams (71% vs 53%; P = 0.02). Gold attendings generally received higher teaching scores compared with non-Gold attendings, and third-year medical students on the Gold team scored significantly higher on the shelf exam compared with non–Gold team students (84 vs 82; P = 0.006). CONCLUSIONS Academic hospitalists working within a systems redesign intervention were able to improve healthcare-worker communication and enhance learner education without increasing patient length of stay or readmission rates. Journal of Hospital Medicine 2013;8:702–710. 2013 The Authors. Journal of Hospital Medicine published by Wiley Periodicals, Inc. on behalf of Society of Hospital Medicine

Hospitalized adult patients are at increased risk for adverse outcomes, particularly when undergoing invasive procedures that include indwelling urinary catheterization. This study identified factors associated with nurses' adoption of an evidence-based practice to reduce the duration of catheterization and potential for catheter-associated urinary tract infections in hospitalized adults.