Summary Background Antimicrobial stewardship is advocated to improve the quality of antimicrobial use. We did a systematic review and meta-analysis to assess whether antimicrobial stewardship ...objectives had any effects in hospitals and long-term care facilities on four predefined patients' outcomes: clinical outcomes, adverse events, costs, and bacterial resistance rates. Methods We identified 14 stewardship objectives and did a separate systematic search for articles relating to each one in Embase, Ovid MEDLINE, and PubMed. Studies were included if they reported data on any of the four predefined outcomes in patients in whom the specific antimicrobial stewardship objective was assessed and compared the findings in patients in whom the objective was or was not met. We used a random-effects model to calculate relative risk reductions with relative risks and 95% CIs. Findings We identified 145 unique studies with data on nine stewardship objectives. Overall, the quality of evidence was generally low and heterogeneity between studies was mostly moderate to high. For the objectives empirical therapy according to guidelines, de-escalation of therapy, switch from intravenous to oral treatment, therapeutic drug monitoring, use of a list of restricted antibiotics, and bedside consultation the overall evidence showed significant benefits for one or more of the four outcomes. Guideline-adherent empirical therapy was associated with a relative risk reduction for mortality of 35% (relative risk 0·65, 95% CI 0·54–0·80, p<0·0001) and for de-escalation of 56% (0·44, 0·30–0·66, p<0·0001). Evidence of effects was less clear for adjusting therapy according to renal function, discontinuing therapy based on lack of clinical or microbiological evidence of infection, and having a local antibiotic guide. We found no reports for the remaining five stewardship objectives or for long-term care facilities. Interpretation Our findings of beneficial effects on outcomes with nine antimicrobial stewardship objectives suggest they can guide stewardship teams in their efforts to improve the quality of antibiotic use in hospitals. Funding Dutch Working Party on Antibiotic Policy and Netherlands National Institute for Public Health and the Environment.
Objective To evaluate the effectiveness of quality improvement collaboratives in improving the quality of care.Data sources Relevant studies through Medline, Embase, PsycINFO, CINAHL, and Cochrane ...databases.Study selection Two reviewers independently extracted data on topics, participants, setting, study design, and outcomes.Data synthesis Of 1104 articles identified, 72 were included in the study. Twelve reports representing nine studies (including two randomised controlled trials) used a controlled design to measure the effects of the quality improvement collaborative intervention on care processes or outcomes of care. Systematic review of these nine studies showed moderate positive results. Seven studies (including one randomised controlled trial) reported an effect on some of the selected outcome measures. Two studies (including one randomised controlled trial) did not show any significant effect.Conclusions The evidence underlying quality improvement collaboratives is positive but limited and the effects cannot be predicted with great certainty. Considering that quality improvement collaboratives seem to play a key part in current strategies focused on accelerating improvement, but may have only modest effects on outcomes at best, further knowledge of the basic components effectiveness, cost effectiveness, and success factors is crucial to determine the value of quality improvement collaboratives.
To evaluate the use of a COVID-19 app containing relevant information for healthcare workers (HCWs) in hospitals and to determine user experience.
A smartphone app (Firstline) was adapted to ...exclusively contain local COVID-19 policy documents and treatment protocols. This COVID-19 app was offered to all HCWs of a 900-bed tertiary care hospital. App use was evaluated with user analytics and user experience in an online questionnaire.
A total number of 1168 HCWs subscribed to the COVID-19 app which was used 3903 times with an average of 1 minute and 20 seconds per session during a three-month period. The number of active users peaked in April 2020 with 1017 users. Users included medical specialists (22.3%), residents (16.5%), nurses (22.2%), management (6.2%) and other (26.5%). Information for HCWs such as when to test for SARS-CoV-2 (1214), latest updates (1181), the COVID-19 telephone list (418) and the SARS-CoV-2 / COVID-19 guideline (280) were the most frequently accessed advice. Seventy-one users with a mean age of 46.1 years from 19 different departments completed the questionnaire. Respondents considered the COVID-19 app clear (54/59; 92%), easy-to-use (46/55; 84%), fast (46/52; 88%), useful (52/56; 93%), and had faith in the information (58/70; 83%). The COVID-19 app was used to quickly look up something (43/68; 63%), when no computer was available (15/68; 22%), look up / dial COVID-related phone numbers (15/68; 22%) or when walking from A to B (11/68; 16%). Few respondents felt app use cost time (5/68; 7%).
Our COVID-19 app proved to be a relatively simple yet innovative tool that was used by HCWs from all disciplines involved in taking care of COVID-19 patients. The up-to-date app was used for different topics and had high user satisfaction amongst questionnaire respondents. An app with local hospital policy could be an invaluable tool during a pandemic.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Guidelines for developing and implementing stewardship programmes include recommendations on appropriate antibiotic use to guide the stewardship team’s choice of potential stewardship objectives. ...They also include recommendations on behavioural change interventions to guide the team’s choice of potential interventions to ensure that professionals actually use antibiotics appropriately in daily practice.
To summarize the evidence base of both appropriate antibiotic use recommendations (the ‘what’) and behavioural change interventions (the ‘how’) in hospital practice.
Published systematic reviews/Medline.
The literature shows low-quality evidence of the positive effects of appropriate antibiotic use in hospital patients. The literature shows that any behavioural change intervention might work to ensure that professionals actually perform appropriate antibiotic use recommendations in daily practice. Although effects were overall positive, there were large differences in improvement between studies that tested similar change interventions.
The literature showed a clear need for studies that apply appropriate study designs– (randomized) controlled designs—to test the effectiveness of appropriate antibiotic use on achieving meaningful outcomes. Most current studies used designs prone to confounding by indication. In the process of selecting behavioural change interventions that might work best in a chosen setting, much should be learned from behavioural sciences. The challenge for stewardship teams lies in selecting change interventions on the careful assessment of barriers and facilitators, and on a theoretical base while linking determinants to change interventions. Future studies should apply more robust designs and evaluations when assessing behavioural change interventions.
A consistent finding in articles on quality improvement in health care is that change is difficult to achieve. According to the research literature, the majority of interventions are targeted at ...health care professionals. But success in achieving change may be influenced by factors other than those relating to individual professionals, and theories may help explain whether change is possible. This article argues for a more systematic use of theories in planning and evaluating quality-improvement interventions in clinical practice. It demonstrates how different theories can be used to generate testable hypotheses regarding factors that influence the implementation of change, and it shows how different theoretical assumptions lead to different quality-improvement strategies.
To curb increasing resistance rates, responsible antimicrobial use (AMU) is needed, both in human and veterinary medicine. In human healthcare, antimicrobial stewardship programmes (ASPs) have been ...implemented worldwide to improve appropriate AMU. No ASPs have been developed for and implemented in companion animal clinics yet.
The objective of the present study was to implement and evaluate the effectiveness of an ASP in 44 Dutch companion animal clinics. The objectives of the ASP were to increase awareness on AMU, to decrease total AMU whenever possible and to shift AMU towards 1st choice antimicrobials, according to Dutch guidelines on veterinary AMU.
The study was designed as a prospective, stepped-wedge, intervention study, which was performed from March 2016 until March 2018. The multifaceted intervention was developed using previous qualitative and quantitative research on current prescribing behaviour in Dutch companion animal clinics. The number of Defined Daily Doses for Animal (DDDAs) per clinic (total, 1st, 2nd and 3rd choice AMU) was used to quantify systemic AMU. Monthly AMU data were described using a mixed effect time series model with auto-regression. The effect of the ASP was modelled using a step function and a change in the (linear) time trend.
A statistically significant decrease of 15% (7%-22%) in total AMU, 15% (5%-24%) in 1st choice AMU and 26% (17%-34%) in 2nd choice AMU was attributed to participation in the ASP, on top of the already ongoing time trends. Use of 3rd choice AMs did not significantly decrease by participation in the ASP. The change in total AMU became more prominent over time, with a 16% (4%-26%) decrease in (linear) time trend per year.
This study shows that, although AMU in Dutch companion animal clinics was already decreasing and changing, AMU could be further optimised by participation in an antimicrobial stewardship programme.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Summary Antibiotics have dramatically changed the prognoses of patients with severe infectious diseases over the past 50 years. However, the emergence and dissemination of resistant organisms has ...endangered the effectiveness of antibiotics. One possible approach to the resistance problem is the appropriate use of antibiotic drugs for preventing and treating infections. This Review describes how the volume and appropriateness of antibiotic use in hospitals vary between countries, hospitals, and physicians. At each specific level—cultural, contextual, and behavioural—we discuss the determinants that influence hospital antibiotic use and the possible improvement strategies to make it more appropriate. Changing hospital antibiotic use is a challenge of formidable complexity. On each level, many determinants play a part, so that the measures or strategies undertaken to improve antibiotic use need to be equally diverse. Although various strategies for improving antibiotic use are available, a programme with activities at all three levels is needed for hospitals. Evaluating these programme activities in a way that provides external validity of the conclusions is crucial.
As of December 2019, pregnant women in the Netherlands are offered pertussis vaccination to protect their newborn infant against pertussis infection. However, the manner in which pregnant women ...decide about this maternal pertussis vaccination is largely unknown. The aim of this study is to gain insight into the decision-making process regarding maternal pertussis vaccination, and to explore the related needs among the vaccine-hesitant subgroup of orthodox Protestant women.
Charmaz's grounded theory approach was used to develop a decision-making framework. To construct this framework we used an explorative multimethod approach in which in-depth interviews and online focus groups were supplemented by a literature search and research group meetings. This study was carried out in a hypothetical situation since the maternal pertussis vaccination had yet to be implemented in the Dutch immunisation programme at the time of the study.
Twenty-five orthodox Protestant women participated in an interview, an online focus group, or in both. The findings of this study resulted in a decision-making framework that included three stages of decision-making; an Orientation stage, a value-based Deliberation stage, and Final decision stage. The Orientation stage included the needs for decision-making categorised into Information needs and Conversation needs. Women indicated that -if they were to receive sufficient time for Orientation and Deliberation- they would be able to reach the stage of Final decision.
The decision-making framework resulting from our findings can be used by health care professionals to provide women with information and consultation in the decision-making process. Future studies should investigate whether the stages of and needs for decision-making can be found across other vaccine-hesitant subgroups and vaccinations.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
This study investigated the association between appropriate antibiotic use, defined by validated quality indicators (QIs), and length of hospital stay in 1252 patients with complicated urinary tract ...infections. A dose-response relationship between good QI performance and shorter duration of stay was found.
Background.
To define appropriate antibiotic use for patients with a complicated urinary tract infection (UTI), we developed in a previous study a key set of 4 valid, guideline-based quality indicators (QIs). In the current study, we evaluated the association between appropriate antibiotic use for patients with a complicated UTI, as defined by these QIs, and length of hospital stay (LOS).
Methods.
A retrospective, observational multicenter study included 1252 patients with a complicated UTI, hospitalized at internal medicine and urology departments of 19 university and nonuniversity Dutch hospitals. Data from the patients' medical charts were used to calculate QI performance scores. Multilevel mixed-model analyses were performed to relate LOS to QI performance (appropriate use or not). We controlled for the potential confounders sex, age, (urological) comorbidity, febrile UTI, and intensive care unit admission <24 hours.
Results.
Prescribing therapy in accordance with local hospital guidelines was associated with a shorter LOS (7.3 days vs 8.7 days; P = .02), as was early intravenous-oral switching (4.8 days vs 9.1 days; P < .001). There was an inverse relationship between the proportion of appropriate use in a patient (QI sum score/number of applicable QIs) and LOS (9.3 days for lower tertile vs 7.2 days for upper tertile; overall P < .05).
Conclusions.
Appropriate antibiotic use in patients with a complicated UTI seems to reduce length of hospital stay and therefore favors patient outcome and healthcare costs. In particular, adherence to the total set of QIs showed a significant dose-response relationship with a shorter LOS.
Background. An important requirement for an effective antibiotic stewardship program is the ability to measure appropriateness of antibiotic use. The aim of this study was to develop quality ...indicators (QIs) that can be used to measure appropriateness of antibiotic use in the treatment of all bacterial infections in hospitalized adult patients. Methods. A RAND-modified Delphi procedure was used to develop a set of QIs. Potential QIs were retrieved from the literature. In 2 questionnaire mailings with an in-between face-to-face consensus meeting, an international multidisciplinary expert panel of 17 experts appraised and prioritized these potential QIs. Results. The literature search resulted in a list of 24 potential QIs. Nine QIs describing recommended care at patient level were selected: (1) take 2 blood cultures, (2) take cultures from suspected sites of infection, (3) prescribe empirical antibiotic therapy according to local guideline, (4) change empirical to pathogen-directed therapy, (5) adapt antibiotic dosage to renal function, (6) switch from intravenous to oral, (7) document antibiotic plan, (8) perform therapeutic drug monitoring, and (9) discontinue antibiotic therapy if infection is not confirmed. Two QIs describing recommended care at the hospital level were also selected: (1) a local antibiotic guideline should be present, and (2) these local guidelines should correspond to the national antibiotic guidelines. Conclusions. The selected QIs can be used in antibiotic stewardship programs to determine for which aspects of antibiotic use there is room for improvement. At this moment we are testing the clinimetric properties of these QIs in 1800 hospitalized patients, in 22 Dutch hospitals.
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