Inappropriate use of antimicrobials is linked to the development and spread of drug-resistant pathogens and is associated with increased morbidity, mortality, lengths of hospital stay, and health ...care costs. "Antimicrobial stewardship" is the umbrella term for an evidence-based knowledge translation strategy involving comprehensive quality improvement activities to optimize the use of antimicrobials, improve patient outcomes, reduce the development of antimicrobial resistance and hospital-acquired infections such as Clostridium difficile, and decrease health care costs.
To assess the perceptions and experiences of antimicrobial stewardship program leaders in terms of clinicians' attitudes toward and behaviours related to antimicrobial prescribing.
In this qualitative study, semistructured interviews were conducted with 6 antimicrobial stewards (2 physicians and 4 pharmacists) at 3 academic hospitals between June and August 2013.
The following 3 key themes emerged from the interviews: getting the right people on board, building collegial relationships, and rapidly establishing a track record. The study results elucidated the role and mechanisms that the program leader and other antimicrobial stewards used to influence other clinicians to engage in effective utilization of antimicrobials. The results also highlighted the methods employed by members of the antimicrobial stewardship team to tailor their strategies to the local context and to stakeholders of participating units; to gain credibility by demonstrating the impact of the antimicrobial stewardship program on clinical outcomes and cost; and to engage senior leaders to endorse and invest in the antimicrobial stewardship program, thereby adding to the antimicrobial stewards' credibility and their ability to influence the uptake of effective antimicrobial use.
Collectively, these results offer insight into processes and mechanisms of influence employed by antimicrobial stewards to enhance antimicrobial use among clinicians, which can in turn inform future implementation of antimicrobial stewardship and strategies for organizational change in hospitals.
Obstetric hemorrhage is one of the most common causes of maternal morbidity and mortality. The measurement of quantitative blood loss (QBL) at delivery prevents clinicians from failing to recognize ...hemorrhage in healthy obstetric patients who initially compensate for excessive blood loss. The purpose of this project was to improve the compliance of labor and delivery nurses in a community hospital with consistent QBL measurement. Key theories that formed the basis for the project were Lewin’s theory of planned change and homeostasis. The project question addressed was: Is the use of weekly scorecards to provide feedback to nurses with both blinded individual data and aggregate unit data associated with an increase in the percent of patients with blood loss at delivery documented as a QBL measurement over a 12-week period of time? A blinded scorecard of the percent of deliveries attended by each nurse that had QBL documented and an aggregate run chart of the percent of all deliveries with QBL documented were posted in the unit weekly. The postings included discussions of means to enhance facilitators of and decrease barriers to QBL measurement. Over 12 weeks, the percent of deliveries with QBL documented increased from 22.7% to 80.0%. This result is consistent with previous reports that clear and objective feedback from scorecards is associated with improvement in performance. Scorecard feedback may be explored to determine if it is associated with improvement of other nursing practices. This project has implications for positive social change as it may contribute to a reduction in preventable maternal deaths. Decreasing maternal morbidity and mortality supports the health of women in a population and influences the health of the next generation.
Abstract
Background
Antibiotic use has drastically changed the course of modern medicine. However, the overuse and often inappropriate use of antibiotics has led to the development of resistant ...strains of bacteria. Increasingly, healthcare systems struggle to deal with the burden of fighting infections that no longer respond to common antibiotic-based treatments. One strategy used to combat antibiotic resistance is the implementation of hospital-based Antimicrobial Stewardship Programs (ASP). ASP structure among the top U.S hospitals may provide insight into which of the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) ASP recommendations are most efficacious given limited resources. We thus administered a survey to better understand the elements of an ASP that are utilized at these top-rated hospitals.
Methods
We surveyed the 50 highest ranking hospitals in various specialties using the 2015-2016 U.S News lists of top hospitals. This corresponded to 137 adult and 70 pediatric sites. We inquired as to which components of the 2016 IDSA and SHEA ASP guidelines were implemented at each site. Appropriate persons at each hospital were contacted by telephone and email.
Results
Overall, 102 of 207 hospitals responded (49.3%). Of these 87.2% had an active ASP, and 57.1% were active for more than 5 years. Interventions most widely adopted included prospective auditing of antimicrobial usage (n = 65, 87.8%), pre-authorization of antimicrobials (n = 61, 82.4%), and antimicrobials restricted to infectious disease physicians (n = 52, 70.3%). The most widely implemented optimization strategies included promoting transition from intravenous to oral antibiotics (n = 68, 93.2%) and strategies to minimize antimicrobial therapy duration (n = 56, 76.7%). The least common interventions included antimicrobial time-outs (n = 17, 23.0%) and ASP intervention in cases with high risk of Clostridium Difficile infection (n = 27, 36.5%). The least common optimization strategy was the use of time-sensitive stop orders (n = 27, 37.0%).
Conclusion
Most leading U.S hospitals selectively implement IDSA and SHEA recommendations. Understanding the structure of ASPs in these hospitals will assist other hospitals in implementing their programs.
Disclosures
All authors: No reported disclosures.
Abstract
Background
Surgical site infections are common causes of healthcare-associated infections. Using surgical antimicrobial prophylaxis (SAP) is a complex process that can reduce these rates if ...performed correctly. While antimicrobial stewardship programs have developed guidelines for SAP, there has been less focus on understanding and modifying the behavioral and contextual factors required to optimize prophylaxis use. We performed chart reviews and workflow analyses to develop interventions based on a theoretical framework to improve SAP use in two academic hospitals.
Methods
SAP use during a one month period (October 2016) was analyzed for orthopedic and general surgery procedures by chart review. The primary outcomes of interest included SAP choice, preoperative timing, intraoperative re-dosing, and postoperative continuation. Structured workflow analyses were performed to understand the processes involved in SAP ordering and administration. These findings were applied to the Theoretical Domains Framework (TDF) to develop theory-based interventions.
Results
We reviewed 88 orthopedic and 63 general surgery procedures. Adherence to institutional guidelines for prophylaxis choice was low in both orthopedic (55%) and general surgery (70%). For general surgery, preoperative timing was incorrect in 25% of cases, re-dosing for procedure duration was incorrect in 59% of cases, and re-dosing for blood loss was not routinely performed. Alternatively, for orthopedic surgery cefazolin was re-dosed too early, at a median of 93 minutes (n = 42), and postop antibiotic use was continued for 10 days in all 14 aseptic hip revisions. There was variation in practice patterns among orthopedic surgeons. Using TDF, we identified barriers among numerous theoretical domains for re-dosing (knowledge; memory, attention, and decision processes; environmental context and resources), choice of antibiotic and postoperative duration (knowledge; beliefs about consequences; emotion; social influences).
Conclusion
We identified suboptimal SAP use in two surgical services, each with distinct deficiencies. Performing in-depth chart reviews and workflow analyses characterized the specific behavioural and contextual barriers that require intervention.
Disclosures
All authors: No reported disclosures.
Background: Staphylococcus aureus bacteremia (SAB) results in high morbidity and mortality. Infectious diseases (ID) consultation for SAB has been associated with improved process measures and ...outcomes in SAB. Recent guidelines have been implemented to include ID consultation in the management of positive SAB culture. We sought to determine whether a policy of mandatory ID consultation for SAB would improve management and mortality. Methods: We conducted a retrospective quasi-experimental study of patients with SAB at three academic hospitals comparing adherence to process measures, and mortality as a secondary measure, before and after implementation of a hospital policy of mandatory ID consultation for all cases of SAB. Results: ID consultation was performed in 239/411 (58%) patients in the pre-intervention period and 196/205 (96%) patients in the post-intervention period (p < 0.0001). Compared with pre-intervention, mandatory consultation was associated with better adherence to quality process measures including echocardiography (319/411 (78%) versus 186/205 (91%) p < 0.0001), subsequent blood culture within 2–4 days (174/411 (42%) versus 143/205 (70%) p < 0.0001) and avoidance of vancomycin as definitive antibiotic therapy for methicillin-susceptible S. aureus (MSSA) (54/347 (16%) versus 13/177 (7%) p = 0.0082). In-hospital mortality rate was 94/411 (23%) in the pre-intervention group and 33/205 (16%) in the post-intervention group. The unadjusted sub-distribution hazard ratio (sHR) for in-hospital mortality in the postintervention period was 0.67 (95% CI 0.45 to 0.99, p = 0.0447). After adjusting for significant prognostic factors, post-intervention in-hospital mortality had an sHR of 0.79 (95% CI 0.52 to 1.20, p = 0.2686). Conclusions: A policy of mandatory ID consultation for patients with SAB was easily implemented leading to consultation in nearly all SAB patients and improved adherence to standard of care process measures. In-hospital mortality did not improve significantly after adjusting for patient characteristics. Our study provides the framework to support this easily implemented institutional policy in academic hospitals.
Chest computed tomography (CT) findings of nodules, ground glass opacities, and consolidations are often interpreted as representing invasive fungal infection in individuals with febrile neutropenia. ...We assessed whether these CT findings were present in asymptomatic individuals with acute myeloid leukemia (AML) at low risk of invasive fungal disease. A retrospective study of consecutive asymptomatic adult patients with newly diagnosed AML over a 2-year period was performed at a tertiary care oncology center. Radiology reports of baseline chest CTs were reviewed. Of 145 CT scans, the majority (88%) had pulmonary abnormalities. Many (70%) had one or both of unspecified opacities (52%) and nodules (49%). Ground glass opacities (18%) and consolidations (12%) occurred less frequently. Radiologists suggested pneumonia as a possible diagnosis in 32% (n = 47) of scans. Chest CT may result in over-diagnosis of invasive fungal disease in individuals with febrile neutropenia if interpreted without correlation to the patients' clinical status.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
PDF
