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Patton LJ, Morris A, Nash A, Richards K, Huntington L, Batchelor L, Harris J, Young V, Howe CJ. Formative Evaluation of CLABSI Adoption and Sustainment Interventions in a Pediatric Intensive Care Unit. Pediatr Qual Saf 2024; 9:e719. [PMID: 38576891 PMCID: PMC10990306 DOI: 10.1097/pq9.0000000000000719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 01/17/2024] [Indexed: 04/06/2024] Open
Abstract
Background Pediatric patients require central venous catheters to maintain adequate hydration, nutritional status, and delivery of life-saving medications in the pediatric intensive care unit. Although central venous catheters provide critical medical therapies, their use increases the risk of severe infection, morbidity, and mortality. Adopting an evidence-based central line-associated bloodstream infection (CLABSI) bundle to guide nursing practice can decrease and sustain low CLABSI rates, but reliable and consistent implementation is challenging. This study aimed to conduct a mixed-methods formative evaluation to explore CLABSI bundle implementation strategies in a PICU. Methods The team used The Consolidated Framework for Implementation Research to develop the interview guide and data analysis plan. Results Facilitators and barriers for the CLABSI bundle occurred in four domains: inner setting, process, characteristics of individuals, and innovation characteristics in each cycle that led to recommended implementation strategy opportunities. The champion role was a major implementation strategy that facilitated the adoption and sustainment of the CLABSI bundle. Conclusions Implementation Science Frameworks, such as Consolidated Framework for Implementation Research (CFIR), can be a beneficial framework to guide quality improvement efforts for evidence-based practices such as the CLABSI bundle. Using a champion role in the critical care setting may be an important implementation strategy for CLABSI bundle adoption and sustainment efforts.
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Affiliation(s)
- Lindsey J. Patton
- From the Children’s Critical Care Services and Nursing Research, Dallas, Tex
| | - Angelica Morris
- From the Children’s Critical Care Services and Nursing Research, Dallas, Tex
| | - Amanda Nash
- From the Children’s Critical Care Services and Nursing Research, Dallas, Tex
| | - Kendel Richards
- From the Children’s Critical Care Services and Nursing Research, Dallas, Tex
| | - Leslie Huntington
- From the Children’s Critical Care Services and Nursing Research, Dallas, Tex
| | - Lori Batchelor
- From the Children’s Critical Care Services and Nursing Research, Dallas, Tex
| | - Jenna Harris
- From the Children’s Critical Care Services and Nursing Research, Dallas, Tex
| | - Virginia Young
- From the Children’s Critical Care Services and Nursing Research, Dallas, Tex
| | - Carol J. Howe
- Harris College of Nursing, Texas Christian University, Fort Worth, Tex
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Developing the Key Driver Diagram by Analyzing Home Central Line Caregiver Proficiency Factors. Pediatr Qual Saf 2023; 8:e638. [PMID: 36926216 PMCID: PMC10013623 DOI: 10.1097/pq9.0000000000000638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/10/2023] [Indexed: 03/16/2023] Open
Abstract
Caregivers of pediatric oncology and stem cell transplant patients often care for central lines (CLs) at home. Methods to achieve caregiver CL care proficiency, and interventions designed with caregiver input are lacking. Methods Caregivers of pediatric oncology and stem cell transplant patients patients with an external CL or removed within 2 weeks were eligible for a survey assessing knowledge, the value of training strategies, and comfort. We mapped responses (n = 79) and acceptability/challenges of introducing a pilot caregiver CL teach-back clinic program onto the capability, opportunity, motivation behavioral (COM-B) model of change to identify drivers of caregiver CL care proficiency. A working group, including caregivers, refined and approved a final driver diagram. Results Survey: Ninety-four percent of caregivers answered knowledge questions correctly (capability); 95% considered hands-on training helpful (opportunity); 53% were not very comfortable with CL care (motivation). Teach-back: Seventy-nine percent of caregivers were interested in a teach-back as additional training; 38% participated (opportunity); 20% refused participation due to being overwhelmed/not having time (motivation). Thirty-three percent of participants had a CL proficiency assessment (capability). Drivers of home caregiver CL care proficiency included: support for the caregiver's physical capability to perform CL care; enabling the CL care nurse trainer role; facilitating and increasing training opportunities, and engaging caregivers early and continuously to motivate proficiency development appropriately. Conclusions An approach centered on caregivers as main stakeholders can identify drivers to co-design an intervention for improved home CL care delivery. A standardized process to train and evaluate caregivers with multiple hands-on opportunities might be beneficial.
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von Lengerke T, Tomsic I, Krosta KME, Ebadi E, Keil V, Buchta F, Luz JK, Schaumburg T, Kolbe-Busch S, Chaberny IF. Tailoring implementation interventions of different order in infection prevention and control: A cascadic logic model (IPC-CASCADE). FRONTIERS IN HEALTH SERVICES 2023; 2:960854. [PMID: 36925806 PMCID: PMC10012664 DOI: 10.3389/frhs.2022.960854] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 12/21/2022] [Indexed: 01/19/2023]
Abstract
Implementation interventions in infection prevention and control (IPC) differ by recipients. The two target groups are healthcare workers directly involved in patient care ("frontline") and IPC professionals as proxy agents, that is, implementation support practitioners. While both types of implementation interventions aim to promote compliance with clinical interventions to prevent healthcare-associated infections (HAI), their tailoring may be vastly different, for example, due to different behavioural outcomes. Additionally, IPC teams, as recipients of empowering tailored interventions, are under-researched. To overcome this gap and improve conceptual clarity, we proposed a cascadic logic model for tailored IPC interventions (IPC-CASCADE). In the model, we distinguished between interventions by IPC professionals targeting clinicians and those targeting IPC professionals (first- and second-order implementation interventions, respectively). Tailoring implies selecting behaviour change techniques matched to prospectively-assessed determinants of either clinician compliance (in first-order interventions) or interventions by IPC professionals for frontline workers (in second-order interventions). This interventional cascade is embedded in the prevailing healthcare system. IPC-CASCADE is horizontally structured over time and vertically structured by hierarchy or leadership roles. IPC-CASCADE aims to highlight the potential of increasing the impact of tailored interventions by IPC professionals for clinicians (to improve their compliance) via tailored interventions for IPC professionals (to improve their work as proxy agents). It underlines the links that IPC professionals define between macro contexts (healthcare and hospitals) and frontline workers in HAI prevention. It is specific, i.e., "tailored" to IPC, and expected to assist implementation science to better conceptualise tailoring.
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Affiliation(s)
- Thomas von Lengerke
- Department of Medical Psychology, Hannover Medical School, Center for Public Health and Health Care, Hannover, Germany
| | - Ivonne Tomsic
- Department of Medical Psychology, Hannover Medical School, Center for Public Health and Health Care, Hannover, Germany
| | - Karolin M. E. Krosta
- Department of Medical Psychology, Hannover Medical School, Center for Public Health and Health Care, Hannover, Germany
| | - Ella Ebadi
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Center for Laboratory Medicine, Hannover, Germany
| | - Valentine Keil
- Department of Medical Psychology, Hannover Medical School, Center for Public Health and Health Care, Hannover, Germany
- Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Leipzig University Hospital, Interdisciplinary Center for Infectious Medicine, Leipzig, Germany
| | - Frederike Buchta
- Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Leipzig University Hospital, Interdisciplinary Center for Infectious Medicine, Leipzig, Germany
| | - J. Katrin Luz
- Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Leipzig University Hospital, Interdisciplinary Center for Infectious Medicine, Leipzig, Germany
| | - Tiffany Schaumburg
- Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Leipzig University Hospital, Interdisciplinary Center for Infectious Medicine, Leipzig, Germany
| | - Susanne Kolbe-Busch
- Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Leipzig University Hospital, Interdisciplinary Center for Infectious Medicine, Leipzig, Germany
| | - Iris F. Chaberny
- Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Leipzig University Hospital, Interdisciplinary Center for Infectious Medicine, Leipzig, Germany
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Nakaya Y, Imasaki M, Shirano M, Shimizu K, Yagi N, Tsutsumi M, Yoshida M, Yoshimura T, Hayashi Y, Nakao T, Yamane T. Peripherally inserted central venous catheters decrease central line-associated bloodstream infections and change microbiological epidemiology in adult hematology unit: a propensity score-adjusted analysis. Ann Hematol 2022; 101:2069-2077. [PMID: 35780253 DOI: 10.1007/s00277-022-04908-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/25/2022] [Indexed: 11/01/2022]
Abstract
Peripherally inserted central venous catheters (PICCs) have a potential advantage in preventing central line-associated bloodstream infection (CLABSI) compared with the centrally inserted ones (CICCs). However, due to a limited number of studies with insufficient statistical evaluation, the superiority of PICCs is difficult to be generalized in adult hematology unit. We conducted a single-center retrospective study and compared the risk of CLABSI between 472 CICCs and 557 PICCs inserted in adult patients with hematological disorders through conventional multivariate models and a propensity score-adjusted analysis. The overall CLABSI incidence in CICCs and PICCs was 5.11 and 3.29 per 1000 catheter days (P = 0.024). The multivariate Cox regression analysis (hazard ratio [HR]: 0.48; 95% confidence interval [CI]: 0.31-0.75; P = 0.001) and Fine-Gray subdistribution analysis (HR: 0.59; 95% CI: 0.37-0.93; P = 0.023) demonstrated that PICC was independently associated with a reduced risk of CLABSI. Moreover, the stabilized inverse probability of treatment weighting analysis, which further reduced the selection bias between CICCs and PICCs, showed that PICCs significantly prevented CLABSI (HR: 0.58; 95% CI: 0.35-0.94; P = 0.029). Microbiologically, PICCs showed a significant decrease in gram-positive cocci (P = 0.001) and an increase in gram-positive bacilli (P = 0.002) because of a remarkable reduction in Staphylococci and increase in Corynebacterium species responsible for CLABSI. Our study confirmed that PICC was a superior alternative to CICC in preventing CLABSI in the adult hematology unit, while it posed a microbiological shift in local epidemiology.
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Affiliation(s)
- Yosuke Nakaya
- Department of Hematology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka City, Osaka, 534-0021, Japan.,Department of Hematology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Mika Imasaki
- Department of Infectious Diseases, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka City, Osaka, 534-0021, Japan
| | - Michinori Shirano
- Department of Infectious Diseases, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka City, Osaka, 534-0021, Japan.
| | - Katsujun Shimizu
- Department of Hematology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka City, Osaka, 534-0021, Japan
| | - Naoko Yagi
- Department of Hematology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka City, Osaka, 534-0021, Japan
| | - Minako Tsutsumi
- Department of Hematology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka City, Osaka, 534-0021, Japan.,Department of Hematology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Masahiro Yoshida
- Department of Hematology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka City, Osaka, 534-0021, Japan
| | - Takuro Yoshimura
- Department of Hematology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka City, Osaka, 534-0021, Japan
| | - Yoshiki Hayashi
- Department of Hematology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka City, Osaka, 534-0021, Japan
| | - Takafumi Nakao
- Department of Hematology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka City, Osaka, 534-0021, Japan
| | - Takahisa Yamane
- Department of Hematology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka City, Osaka, 534-0021, Japan
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Woods-Hill CZ, Xie A, Lin J, Wolfe HA, Plattner AS, Malone S, Chiotos K, Szymczak JE. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlab195. [PMID: 35098126 PMCID: PMC8794647 DOI: 10.1093/jacamr/dlab195] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Antimicrobial and diagnostic stewardship initiatives have become increasingly important in paediatric settings. The value of qualitative approaches to conduct stewardship work in paediatric patients is being increasingly recognized. This article seeks to provide an introduction to basic elements of qualitative study designs and provide an overview of how these methods have successfully been applied to both antimicrobial and diagnostic stewardship work in paediatric patients. A multidisciplinary team of experts in paediatric infectious diseases, paediatric critical care and qualitative methods has written a perspective piece introducing readers to qualitative stewardship work in children, intended as an overview to highlight the importance of such methods and as a starting point for further work. We describe key differences between qualitative and quantitative methods, and the potential benefits of qualitative approaches. We present examples of qualitative research in five discrete topic areas of high relevance for paediatric stewardship work: provider attitudes; provider prescribing behaviours; stewardship in low-resource settings; parents’ perspectives on stewardship; and stewardship work focusing on select high-risk patients. Finally, we explore the opportunities for multidisciplinary academic collaboration, incorporation of innovative scientific disciplines and young investigator growth through the use of qualitative research in paediatric stewardship. Qualitative approaches can bring rich insights and critically needed new information to antimicrobial and diagnostic stewardship efforts in children. Such methods are an important tool in the armamentarium against worsening antimicrobial resistance, and a major opportunity for investigators interested in moving the needle forward for stewardship in paediatric patients.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA
- Corresponding author. E-mail:
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, 750 E Pratt St., Baltimore, MD 21202, USA
| | - John Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Heather A. Wolfe
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Alex S. Plattner
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Sara Malone
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Kathleen Chiotos
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Julia E. Szymczak
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
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Herchline D, Rojas C, Shah AA, Fairchild V, Mehta S, Hart J. A Quality Improvement Initiative to Improve Patient Safety Event Reporting by Residents. Pediatr Qual Saf 2022; 7:e519. [PMID: 35071958 PMCID: PMC8782116 DOI: 10.1097/pq9.0000000000000519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/23/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Residents play a key role in patient care at academic medical centers and have unique insights into safety improvement opportunities. At our institution, <1% of safety events were reported by resident trainees. The primary objective of this quality improvement (QI) initiative was to increase the monthly incidence of event reporting by pediatric residents by 20% from baseline within 12 months. METHODS A QI team used the model for improvement to identify barriers to submitting safety event reports. The team used multiple intervention cycles to increase knowledge and promote engagement in event reporting. Interventions included educational tip sheets, a hospital-wide Morbidity and Mortality (M&M) conference, peer recognition and acknowledgment by senior leadership for report submission, and an interactive reporting activity. The outcome measure was monthly number of reports filed by residents. The process measure was the number of unique residents submitting a report each month. Time to complete a report was a balancing measure. RESULTS The number of reports placed by residents increased significantly, with a centerline shift from 15 to 29 reports per month (statistical process control chart-Fig. 3). The number of unique residents submitting reports increased from 10 to 22 per month. The time to complete a report was unchanged. CONCLUSIONS Engaging residents in patient safety initiatives through education, experiential learning, and recognition can increase safety event reporting by residents. Future planned interventions include enhancing safety event reporting technology, developing patient safety faculty and resident champions, and increasing transparency regarding outcomes of safety event reports.
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Affiliation(s)
- Daniel Herchline
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
| | - Christina Rojas
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
| | - Amit A. Shah
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
| | - Victoria Fairchild
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
| | - Sanjiv Mehta
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
| | - Jessica Hart
- From the Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pa
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Enlisting Parents to Decrease Hospital-Acquired Central Line-Associated Infections in the Pediatric Intensive Care Unit. Crit Care Nurs Clin North Am 2021; 33:431-440. [PMID: 34742499 DOI: 10.1016/j.cnc.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Hospital-acquired central line-associated bloodstream infections (CLABSIs) are the leading cause of infections in the pediatric intensive care unit. Bacteria responsible for CLABSIs are spread by health care workers, parents, and families and mitigated by scrupulous attention to hand hygiene and safety prevention strategies. Maintenance bundles are grouped elements, such as hand hygiene, standardized dressing and tubing changes, and aseptic technique for entering a central line, effective in preventing CLABSIs. Nurses can decrease the incidence of CLABSIs by using maintenance bundles and including parents and families in safety prevention strategies."
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Schefft M, Noda A, Godbout E. Aligning Patient Safety and Stewardship: A Harm Reduction Strategy for Children. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2021; 7:138-151. [PMID: 38624879 PMCID: PMC8273156 DOI: 10.1007/s40746-021-00227-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
Purpose of review Review important patient safety and stewardship concepts and use clinical examples to describe how they align to improve patient outcomes and reduce harm for children. Recent findings Current evidence indicates that healthcare overuse is substantial. Unnecessary care leads to avoidable adverse events, anxiety and distress, and financial toxicity. Increases in antimicrobial resistance, venous thromboembolism, radiation exposure, and healthcare costs are examples of patient harm associated with a lack of stewardship. Studies indicate that many tools can increase standardization of care, improve resource utilization, and enhance safety culture to better align safety and stewardship. Summary The principles of stewardship and parsimonious care can improve patient safety for children.
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Affiliation(s)
- Matthew Schefft
- Department of Pediatrics, Division of Hospital Medicine, Children’s Hospital of Richmond at Virginia Commonwealth University Health System, Richmond, Virginia, USA
- Children’s Hospital of Richmond at VCU, 1001 E Marshall St, Richmond, VA 23298 USA
| | - Andrew Noda
- Department of Pharmacy, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Emily Godbout
- Department of Pediatrics, Division of Infectious Disease, Children’s Hospital of Richmond at Virginia Commonwealth University Health System, Richmond, Virginia, USA
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