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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.

Digital cognitive aids have the potential to serve as clinical decision support platforms, triggering alerts about process delays and recommending interventions. In this mixed-methods study, we examined how a digital checklist for pediatric trauma resuscitation could trigger decision support alerts and recommendations. We identified two criteria that cognitive aids must satisfy to support these alerts: (1) context information must be entered in a timely, accurate, and standardized manner, and (2) task status must be accurately documented. Using co-design sessions and near-live simulations, we created two checklist features to satisfy these criteria: a form for entering the pre-hospital information and a progress slider for documenting the progression of a multi-step task. We evaluated these two features in the wild, contributing guidelines for designing these features on cognitive aids to support alerts and recommendations in time- and safety-critical scenarios. [ABSTRACT FROM AUTHOR]

Many health institutions that have adopted electronic health record systems (EHRs) eventually decide to switch to a different one. Cordasco et al. interviewed primary care providers, primary care nurses, and specialty providers involved in referrals following VA's EHR transition. Through stakeholder engagement, Cogan et al. build on these past findings in describing a new and thoughtful research agenda for EHR transitions, taking into account health system priorities and the need to be proactive in optimizing the success of implementation. [Extracted from the article]

Objective: We examine how physicians and nurses use available communication technologies and identify the implications for communication and patient care based on the theory of workarounds.Materials and Methods: We conducted a qualitative study at 4 U.S. hospitals during 2017. Researchers spent 2 weeks at each hospital conducting unit-based observation, shadowing, interviews, and focus groups with nurses and physicians. Using an iterative process, we inductively coded and thematically analyzed data to derive preliminary themes. The theory of workarounds provides an organizational lens on workarounds, consisting of 5 components: antecedents, types, effects, managerial stance, and organizational challenges of workarounds. The first 3 components of the theory helped us to organize and explain our findings.Results: Communication technologies consisted of pagers and telephones. Antecedents to workarounds included one-way information flow, differential access related to differences in technology types, and technology mismatch. Types of workarounds included bypassing a variety of obstacles and substituting for unavailable resources. Direct effects of workarounds included pager fatigue, interruptions in patient care, and potential errors.Discussion: One-way communication technologies created an environment where workarounds could flourish. By placing results within the context of the theory of workarounds, we extend what we know about why and how workarounds develop, and offer strategies to minimize workarounds' adverse effects.Conclusions: Through the theory of workarounds, we see that there is a trajectory to workarounds with potential consequences for clinicians and patients. Two-way communication technologies could minimize workarounds and gaps in information exchange, and reduce unnecessary interruptions and the potential for adverse events. [ABSTRACT FROM AUTHOR]

Behavioral Economic Theory (BE) suggests that the accessibility and low behavioral cost (e.g., effort, money) of watching TV may increase the value (i.e., demand) of TV watching and promote that behavior over alternative sources of reinforcement (e.g., physical activity, PA). [Extracted from the article]

Aims: The association of glycemic variability with microvascular disease complications in type 2 diabetes (T2D) has been under-studied and remains unclear. We investigated this relationship using both Action to Control Cardiovascular Risk in Diabetes (ACCORD) and the Veteran Affairs Diabetes Trial (VADT).Methods: In ACCORD, fasting plasma glucose (FPG) was measured 1 to 3 times/year for up to 84 months in 10 251 individuals. In the VADT, FPG was measured every 3 months for up to 87 months in 1791 individuals. Variability measures included coefficient of variation (CV) and average real variability (ARV) for fasting glucose. The primary composite outcome was time to either severe nephropathy or retinopathy event and secondary outcomes included each outcome individually. To assess the association, we considered variability measures as time-dependent covariates in Cox proportional hazard models. We conducted a meta-analysis across the 2 trials to estimate the risk of fasting glucose variability as well as to assess the heterogenous effects of FPG variability across treatment arms.Results: In both ACCORD and the VADT, the CV and ARV of FPG were associated with development of future microvascular outcomes even after adjusting for other risk factors, including measures of average glycemic control (ie, cumulative average of HbA1c). Meta-analyses of these 2 trials confirmed these findings and indicated FPG variation may be more harmful in those with less intensive glucose control.Conclusions: This post hoc analysis indicates that variability of FPG plays a role in, and/or is an independent and readily available marker of, development of microvascular complications in T2D. [ABSTRACT FROM AUTHOR]

The article announces the contributions of time and expertise provided by the individuals served as reviewers for calendar year 2020.

Unusual speech prosody has long been recognized as a characteristic feature of the speech of individuals diagnosed with Autism Spectrum Disorders (ASD). However, research to determine the exact nature of this difference in speech prosody is still ongoing. Many individuals with verbal autism perform well on tasks testing speech prosody. Nonetheless, their expressive prosody is judged to be unusual by others. We propose that one aspect of this perceived difference in speech prosody in individuals with ASD may be due to a deficit in the ability to entrain—or become more similar—to their conversation partners in prosodic features over the course of a conversation. In order to investigate this hypothesis, 24 children and teens between the ages of 9 and 15 years participated in our study. Twelve of the participants had previously been diagnosed with ASD and the other 12 participants were matched to the ASD participants in age, gender, and non-verbal IQ scores. All participants completed a goal-directed conversation task, which was subsequently analyzed acoustically. Our results suggest (1) that youth diagnosed with ASD entrain less to their conversation partners compared to their neurotypical peers—in fact, children and teens diagnosed with ASD tend to dis-entrain from their conversation partners while their neurotypical peers tend to converge to their conversation partners' prosodic features. (2) Although age interacts differently with prosodic entrainment in youth with and without ASD, this difference is attributable to the entrainment behavior of the conversation partners rather than to those with ASD. (3) Better language skill is negatively correlated with prosodic entrainment for both youth with and without ASD. The observed differences in prosodic entrainment in children and teens with ASD may not only contribute to the perceived unusual prosody in youth with ASD but are also likely to be indicative of their difficulties in social communication, which constitutes a core challenge for individuals with ASD. [ABSTRACT FROM AUTHOR]

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 FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

A global calendar of events related to medical research for 2007 is presented. The "19th World Congress on Fertility and Sterility" will be held in Durban, South Africa on April 29 to May 3. The "4th Congress of the Asia Pacific Society for the Study on Ageing Male" will be held in Bali, Indonesia on May 3-5. The "1st European Congress on the Ageing Male" will be held in Warsaw, Poland on June 14-16.

The article presents calendar of events related to medicine as of 2007. The North American Congress on the Ageing Male will be held in Montreal, Canada on February 8 to 10. Meanwhile, the 19th World Congress on Fertility and Sterility will take place on April 9 to May 3 in Durban, South Africa. Moreover, the 4th Congress of the Asia Pacific Society for the study on Ageing Male will be slated in Bali, Indonesia on May 3 to 5.

Objective The Prevention of Hospital Infections by Intervention and Training (PROHIBIT) project included a cluster-randomised, stepped wedge, controlled study to evaluate multiple strategies to prevent catheter-related bloodstream infection. We report an in-depth investigation of the main barriers, facilitators and contextual factors relevant to successfully implementing these strategies in European acute care hospitals. Methods Qualitative comparative case study in 6 of the 14 European PROHIBIT hospitals. Data were collected through interviews with key stakeholders and ethnographic observations conducted during 2-day site visits, before and 1 year into the PROHIBIT intervention. Qualitative measures of implementation success included intervention fidelity, adaptation to local context and satisfaction with the intervention programme. Results Three meta-themes emerged related to implementation success: 'implementation agendas', 'resources' and 'boundary-spanning'. Hospitals established unique implementation agendas that, while not always aligned with the project goals, shaped subsequent actions. Successful implementation required having sufficient human and material resources and dedicated change agents who helped make the intervention an institutional priority. The salary provided for a dedicated study nurse was a key facilitator. Personal commitment of influential individuals and boundary spanners helped overcome resource restrictions and intrainstitutional segregation. Conclusion This qualitative study revealed patterns across cases that were associated with successful implementation. Consideration of the intervention--context relation was indispensable to understanding the observed outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]