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Al Lawati H, Shin M, Lamkin R, Thompson T, Epshtein I, Mull H, Basnet Thapa D, Drekonja D, Rodriguez-Barradas MC, Xu TH, Gold H, Elwy AR, Strymish J, Branch-Elliman W. Engaging patients in antimicrobial stewardship: co-designed educational tool to improve periprocedural care through de-implementation of guideline-discordant antimicrobial use. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e163. [PMID: 38028930 PMCID: PMC10644164 DOI: 10.1017/ash.2023.420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/19/2023] [Indexed: 12/01/2023]
Abstract
Effective de-implementation models often include replacement of an ineffective practice with an alternative. We co-developed patient education materials as a replacement strategy for inappropriate post-procedural antibiotics in cardiac device procedures. Lessons learned and developed materials may be used to promote infection prevention in other periprocedural settings.
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Affiliation(s)
| | - Marlena Shin
- VA Boston Healthcare System Center for Healthcare Organization and Implementation Research (CHOIR), West Roxbury, MA02132, USA
| | - Rebecca Lamkin
- VA Boston Healthcare System Center for Healthcare Organization and Implementation Research (CHOIR), West Roxbury, MA02132, USA
| | | | - Isabella Epshtein
- VA Boston Healthcare System Center for Healthcare Organization and Implementation Research (CHOIR), West Roxbury, MA02132, USA
| | - Hillary Mull
- VA Boston Healthcare System Center for Healthcare Organization and Implementation Research (CHOIR), West Roxbury, MA02132, USA
- VA Boston Healthcare System, Department of Medicine, Section of Infectious Diseases, West Roxbury, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, USA
| | - Dipandita Basnet Thapa
- VA Boston Healthcare System Center for Healthcare Organization and Implementation Research (CHOIR), West Roxbury, MA02132, USA
- VA Boston Healthcare System, Department of Medicine, Section of Infectious Diseases, West Roxbury, MA, USA
| | - Dimitri Drekonja
- Veterans Affairs Minneapolis Health Care System, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Maria C. Rodriguez-Barradas
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Teena Huan Xu
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Howard Gold
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - A. Rani Elwy
- VA Boston Healthcare System Center for Healthcare Organization and Implementation Research (CHOIR), West Roxbury, MA02132, USA
- Brown University School of Medicine, Providence, RI, USA
| | - Judy Strymish
- VA Boston Healthcare System, Department of Medicine, Section of Infectious Diseases, West Roxbury, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Westyn Branch-Elliman
- VA Boston Healthcare System Center for Healthcare Organization and Implementation Research (CHOIR), West Roxbury, MA02132, USA
- VA Boston Healthcare System, Department of Medicine, Section of Infectious Diseases, West Roxbury, MA, USA
- Harvard Medical School, Boston, MA, USA
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Reyes Dassum S, Mull HJ, Golenbock S, Lamkin RP, Epshtein I, Shin MH, Strymish JM, Blumenthal KG, Colborn K, Branch-Elliman W. A Novel Informatics Tool to Detect Periprocedural Antibiotic Allergy Adverse Events for Near Real-time Surveillance to Support Audit and Feedback. JAMA Netw Open 2023; 6:e2313964. [PMID: 37195660 PMCID: PMC10193175 DOI: 10.1001/jamanetworkopen.2023.13964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/31/2023] [Indexed: 05/18/2023] Open
Abstract
Importance Standardized processes for identifying when allergic-type reactions occur and linking reactions to drug exposures are limited. Objective To develop an informatics tool to improve detection of antibiotic allergic-type events. Design, Setting, and Participants This retrospective cohort study was conducted from October 1, 2015, to September 30, 2019, with data analyzed between July 1, 2021, and January 31, 2022. The study was conducted across Veteran Affairs hospitals among patients who underwent cardiovascular implantable electronic device (CIED) procedures and received periprocedural antibiotic prophylaxis. The cohort was split into training and test cohorts, and cases were manually reviewed to determine presence of allergic-type reaction and its severity. Variables potentially indicative of allergic-type reactions were selected a priori and included allergies entered in the Veteran Affair's Allergy Reaction Tracking (ART) system (either historical [reported] or observed), allergy diagnosis codes, medications administered to treat allergic reactions, and text searches of clinical notes for keywords and phrases indicative of a potential allergic-type reaction. A model to detect allergic-type reaction events was iteratively developed on the training cohort and then applied to the test cohort. Algorithm test characteristics were assessed. Exposure Preprocedural and postprocedural prophylactic antibiotic administration. Main Outcomes and Measures Antibiotic allergic-type reactions. Results The cohort of 36 344 patients included 34 703 CIED procedures with antibiotic exposures (mean [SD] age, 72 [10] years; 34 008 [98%] male patients); median duration of postprocedural prophylaxis was 4 days (IQR, 2-7 days; maximum, 45 days). The final algorithm included 7 variables: entries in the Veteran Affair's hospitals ART, either historic (odds ratio [OR], 42.37; 95% CI, 11.33-158.43) or observed (OR, 175.10; 95% CI, 44.84-683.76); PheCodes for "symptoms affecting skin" (OR, 8.49; 95% CI, 1.90-37.82), "urticaria" (OR, 7.01; 95% CI, 1.76-27.89), and "allergy or adverse event to an antibiotic" (OR, 11.84, 95% CI, 2.88-48.69); keyword detection in clinical notes (OR, 3.21; 95% CI, 1.27-8.08); and antihistamine administration alone or in combination (OR, 6.51; 95% CI, 1.90-22.30). In the final model, antibiotic allergic-type reactions were identified with an estimated probability of 30% or more; positive predictive value was 61% (95% CI, 45%-76%); and sensitivity was 87% (95% CI, 70%-96%). Conclusions and Relevance In this retrospective cohort study of patients receiving periprocedural antibiotic prophylaxis, an algorithm with a high sensitivity to detect incident antibiotic allergic-type reactions that can be used to provide clinician feedback about antibiotic harms from unnecessarily prolonged antibiotic exposures was developed.
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Affiliation(s)
- Samira Reyes Dassum
- Department of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Hillary J. Mull
- Center for Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Samuel Golenbock
- Center for Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts
| | - Rebecca P. Lamkin
- Center for Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts
| | - Isabella Epshtein
- Center for Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts
| | - Marlena H. Shin
- Center for Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts
| | - Judith M. Strymish
- Section of Infectious Disease, Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | | | - Westyn Branch-Elliman
- Center for Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts
- Section of Infectious Disease, Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Branch-Elliman W, Lamkin R, Shin M, Mull HJ, Epshtein I, Golenbock S, Schweizer ML, Colborn K, Rove J, Strymish JM, Drekonja D, Rodriguez-Barradas MC, Xu TH, Elwy AR. Promoting de-implementation of inappropriate antimicrobial use in cardiac device procedures by expanding audit and feedback: protocol for hybrid III type effectiveness/implementation quasi-experimental study. Implement Sci 2022; 17:12. [PMID: 35093104 PMCID: PMC8800400 DOI: 10.1186/s13012-022-01186-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background Despite a strong evidence base and clinical guidelines specifically recommending against prolonged post-procedural antimicrobial use, studies indicate that the practice is common following cardiac device procedures. Formative evaluations conducted by the study team suggest that inappropriate antimicrobial use may be driven by information silos that drive provider belief that antimicrobials are not harmful, in part due to lack of complete feedback about all types of clinical outcomes. De-implementation is recognized as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excess antimicrobial use following cardiac device procedures; however, investigations into strategies that lead to successful de-implementation are limited. The overarching hypothesis to be tested in this trial is that a bundle of implementation strategies that includes audit and feedback about direct patient harms caused by inappropriate prescribing can lead to successful de-implementation of guideline-discordant care. Methods We propose a hybrid type III effectiveness-implementation stepped-wedge intervention trial at three high-volume, high-complexity VA medical centers. The main study intervention (an informatics-based, real-time audit-and-feedback tool) was developed based on learning/unlearning theory and formative evaluations and guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) Framework. Elements of the bundled and multifaceted implementation strategy to promote appropriate prescribing will include audit-and-feedback reports that include information about antibiotic harms, stakeholder engagement, patient and provider education, identification of local champions, and blended facilitation. The primary study outcome is adoption of evidence-based practice (de-implementation of inappropriate antimicrobial use). Clinical outcomes (cardiac device infections, acute kidney injuries and Clostridioides difficile infections) are secondary. Qualitative interviews will assess relevant implementation outcomes (acceptability, adoption, fidelity, feasibility). Discussion De-implementation theory suggests that factors that may have a particularly strong influence on de-implementation include strength of the underlying evidence, the complexity of the intervention, and patient and provider anxiety and fear about changing an established practice. This study will assess whether a multifaceted intervention mapped to identified de-implementation barriers leads to measurable improvements in provision of guideline-concordant antimicrobial use. Findings will improve understanding about factors that impact successful or unsuccessful de-implementation of harmful or wasteful healthcare practices. Trial registration ClinicalTrials.govNCT05020418
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Ahmed M. Patients characteristic, indications, and complications of permanent pacemaker implantation: A prospective single-center study. MEDICAL JOURNAL OF BABYLON 2022. [DOI: 10.4103/mjbl.mjbl_3_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Mull HJ, Stolzmann KL, Shin MH, Kalver E, Schweizer ML, Branch-Elliman W. Novel Method to Flag Cardiac Implantable Device Infections by Integrating Text Mining With Structured Data in the Veterans Health Administration's Electronic Medical Record. JAMA Netw Open 2020; 3:e2012264. [PMID: 32955571 PMCID: PMC7506515 DOI: 10.1001/jamanetworkopen.2020.12264] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
IMPORTANCE Health care-associated infections (HAIs) are preventable, harmful, and costly; however, few resources are dedicated to infection surveillance of nonsurgical procedures, particularly cardiovascular implantable electronic device (CIED) procedures. OBJECTIVE To develop a method that includes text mining of electronic clinical notes to reliably and efficiently measure HAIs for CIED procedures. DESIGN, SETTING, AND PARTICIPANTS In this multicenter, national cohort study using electronic medical record data for patients undergoing CIED procedures in Veterans Health Administration (VA) facilities for fiscal years (FYs) 2016 and 2017, an algorithm to flag cases with a true CIED-related infection based on structured (eg, microbiology orders, vital signs) and free text diagnostic and therapeutic data (eg, procedure notes, discharge summaries, microbiology results) was developed and validated. Procedure data were divided into development and validation data sets. Criterion validity (ie, positive predictive validity [PPV], sensitivity, and specificity) was assessed via criterion-standard manual medical record review. EXPOSURES CIED procedure. MAIN OUTCOMES AND MEASURES The concordance between medical record review and the study algorithm with respect to the presence or absence of a CIED infection. CIED infection in the algorithm included 90-day mortality, congestive heart failure and nonmetastatic tumor comorbidities, CIED or surgical site infection International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes, antibiotic treatment of Staphylococci, a microbiology test of a cardiac specimen, and text documentation of infection in specific clinical notes (eg, cardiology, infectious diseases, inpatient discharge summaries). RESULTS The algorithm sample consisted of 19 212 CIED procedures; 15 077 patients (78.5%) were White individuals, 1487 (15.5%) were African American; 18 766 (97.7%) were men. The mean (SD) age in our sample was 71.8 (10.6) years. The infection detection threshold of predicted probability was set to greater than 0.10 and the algorithm flagged 276 of 9606 (2.9%) cases in the development data set (9606 procedures); PPV in this group was 41.4% (95% CI, 31.6%-51.8%). In the validation set (9606 procedures), at predicted probability 0.10 or more the algorithm PPV was 43.5% (95% CI, 37.1%-50.2%), and overall sensitivity and specificity were 94.4% (95% CI, 88.2%-97.9%) and 48.8% (95% CI, 42.6%-55.1%), respectively. CONCLUSIONS AND RELEVANCE The findings of this study suggest that the method of combining structured and text data in VA electronic medical records can be used to expand infection surveillance beyond traditional boundaries to include outpatient and procedural areas.
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Affiliation(s)
- Hillary J. Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Kelly L. Stolzmann
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Marlena H. Shin
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Emily Kalver
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Marin L. Schweizer
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa, Iowa City
| | - Westyn Branch-Elliman
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Factors influencing uptake of evidence-based antimicrobial prophylaxis guidelines for electrophysiology procedures. Am J Infect Control 2020; 48:668-674. [PMID: 31806236 DOI: 10.1016/j.ajic.2019.10.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Clinical guidelines support early discontinuation of antimicrobials after cardiac device procedures; however, prolonged courses of antimicrobials are common. METHODS We conducted semistructured interviews with 13 electrophysiologists representing diverse geographic and clinical settings of care to identify perceived barriers and facilitators to discontinuing postprocedure antimicrobial prophylaxis as part of a formative evaluation prior to implementing a program to improve uptake of guideline recommendations. A directed content analysis approach was used to map responses to the Implementation Outcomes Framework. RESULTS Data indicated that electrophysiologists were not willing to stop postprocedural antimicrobials, indicating a lack of acceptability of clinical guidelines. Feasibility, fidelity, cost, and appropriateness were also frequently cited. Factors associated with prolonged antimicrobial prescribing included beliefs about lack of harm and possible benefit. There was a strong "cultural inertia" to conform to institutional normative practices. Reasons for conforming ranged from streamlining processes for clinical staff and concerns about being perceived as an "outlier." CONCLUSIONS Institutional culture and beliefs about consequences of cardiac device infections versus antimicrobial use appeared to be major drivers of current practice. The desire to promote institutional standardization suggests that strategies to enhance implementation of prophylaxis guidelines must include facility-level changes, rather than interventions directed only at individual-providers.
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Development and Validation of a Semi-Automated Surveillance Algorithm for Cardiac Device Infections: Insights from the VA CART program. Sci Rep 2020; 10:5276. [PMID: 32210289 PMCID: PMC7093485 DOI: 10.1038/s41598-020-62083-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 03/09/2020] [Indexed: 11/08/2022] Open
Abstract
Procedure-related cardiac electronic implantable device (CIED) infections have high morbidity and mortality, highlighting the urgent need for infection prevention efforts to include electrophysiology procedures. We developed and validated a semi-automated algorithm based on structured electronic health records data to reliably identify CIED infections. A sample of CIED procedures entered into the Veterans' Health Administration Clinical Assessment Reporting and Tracking program from FY 2008-2015 was reviewed for the presence of CIED infection. This sample was then randomly divided into training (2/3) validation sets (1/3). The training set was used to develop a detection algorithm containing structured variables mapped from the clinical pathways of CIED infection. Performance of this algorithm was evaluated using the validation set. 2,107 unique CIED procedures from a cohort of 5,753 underwent manual review; 97 CIED infections (4.6%) were identified. Variables strongly associated with true infections included presence of a microbiology order, billing codes for surgical site infections and post-procedural antibiotic prescriptions. The combined algorithm to detect infection demonstrated high c-statistic (0.95; 95% confidence interval: 0.92-0.98), sensitivity (87.9%) and specificity (90.3%) in the validation data. Structured variables derived from clinical pathways can guide development of a semi-automated detection tool to surveil for CIED infection.
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Mull HJ, Stolzmann K, Kalver E, Shin MH, Schweizer ML, Asundi A, Mehta P, Stanislawski M, Branch-Elliman W. Novel methodology to measure pre-procedure antimicrobial prophylaxis: integrating text searches with structured data from the Veterans Health Administration's electronic medical record. BMC Med Inform Decis Mak 2020; 20:15. [PMID: 32000780 PMCID: PMC6993312 DOI: 10.1186/s12911-020-1031-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/20/2020] [Indexed: 11/11/2022] Open
Abstract
Background Antimicrobial prophylaxis is an evidence-proven strategy for reducing procedure-related infections; however, measuring this key quality metric typically requires manual review, due to the way antimicrobial prophylaxis is documented in the electronic medical record (EMR). Our objective was to electronically measure compliance with antimicrobial prophylaxis using both structured and unstructured data from the Veterans Health Administration (VA) EMR. We developed this methodology for cardiac device implantation procedures. Methods With clinician input and review of clinical guidelines, we developed a list of antimicrobial names recommended for the prevention of cardiac device infection. We trained the algorithm using existing fiscal year (FY) 2008–15 data from the VA Clinical Assessment Reporting and Tracking-Electrophysiology (CART-EP), which contains manually determined information about antimicrobial prophylaxis. We merged CART-EP data with EMR data and programmed statistical software to flag an antimicrobial orders or drug fills from structured data fields in the EMR and hits on text string searches of antimicrobial names documented in clinician’s notes. We iteratively tested combinations of these data elements to optimize an algorithm to accurately classify antimicrobial use. The final algorithm was validated in a national cohort of VA cardiac device procedures from FY2016–2017. Discordant cases underwent expert manual review to identify reasons for algorithm misclassification. Results The CART-EP dataset included 2102 procedures at 38 VA facilities with manually identified antimicrobial prophylaxis in 2056 cases (97.8%). The final algorithm combining structured EMR fields and text note search results correctly classified 2048 of the CART-EP cases (97.4%). In the validation sample, the algorithm measured compliance with antimicrobial prophylaxis in 16,606 of 18,903 cardiac device procedures (87.8%). Misclassification was due to EMR documentation issues, such as antimicrobial prophylaxis documented only in hand-written clinician notes in a format that cannot be electronically searched. Conclusions We developed a methodology with high accuracy to measure guideline concordant use of antimicrobial prophylaxis before cardiac device procedures using data fields present in modern EMRs. This method can replace manual review in quality measurement in the VA and other healthcare systems with EMRs; further, this method could be adapted to measure compliance in other procedural areas where antimicrobial prophylaxis is recommended.
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Affiliation(s)
- Hillary J Mull
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), 150 S. Huntington Ave, Boston, MA, 02130, USA. .,Department of Surgery, Boston University School of Medicine, Boston, MA, USA.
| | - Kelly Stolzmann
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), 150 S. Huntington Ave, Boston, MA, 02130, USA
| | - Emily Kalver
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), 150 S. Huntington Ave, Boston, MA, 02130, USA
| | - Marlena H Shin
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), 150 S. Huntington Ave, Boston, MA, 02130, USA
| | - Marin L Schweizer
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA.,University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Archana Asundi
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Department of Medicine, Division of Infectious Diseases, Boston, MA, USA
| | - Payal Mehta
- VA Boston Healthcare System, Department of Medicine, Sections of Infectious Diseases and Cardiology, Boston, MA, USA
| | - Maggie Stanislawski
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington and Denver, Colorado, USA.,Division of Biomedical Informatics and Personalized Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Westyn Branch-Elliman
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), 150 S. Huntington Ave, Boston, MA, 02130, USA.,VA Boston Healthcare System, Department of Medicine, Sections of Infectious Diseases and Cardiology, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Prolonged antimicrobial prophylaxis following cardiac device procedures increases preventable harm: insights from the VA CART program. Infect Control Hosp Epidemiol 2019; 39:1030-1036. [PMID: 30226128 DOI: 10.1017/ice.2018.170] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The rate of cardiovascular implantable electronic device (CIED) infection is increasing coincident with an increase in the number of device procedures. Preprocedural antimicrobial prophylaxis reduces CIED infections; however, there is no evidence that prolonged postprocedural antimicrobials additionally reduce risk. Thus, we sought to quantify the harms associated with this approach. OBJECTIVE To measure the association between Clostridium difficile infection (CDI), acute kidney injury (AKI) and receipt of prolonged postprocedural antimicrobials. METHODS CIED procedures entered into the VA Clinical Assessment Reporting and Tracking Electrophysiology (CART-EP) database during fiscal years 2008-2016 were included. The primary outcome was 90-day incidence of CDI and the secondary outcome was the 7-day incidence of AKI. The primary exposure measure was duration of postprocedural antimicrobial therapy. Associations were measured using Cox-proportional hazards and binomial regression. RESULTS Prolonged postprocedural antimicrobial therapy was identified following 3,331 of 6,497 CIED procedures (51.3%), and the median duration of prophylaxis was 5 days. Prolonged postprocedural antimicrobial use was associated with increased risk of CDI (hazard ratio [HR], 2.90; 95% confidence interval [CI], 1.54-5.46). Of the 27 patients who developed CDI, 11 subsequently died. Postprocedural antimicrobial use with ≥2 antimicrobials was associated with an increased risk of AKI (OR, 4.16; 95% CI, 2.50-6.90). The impact was particularly significant when one of the dual agents prescribed was vancomycin (adjusted OR, 8.41; 95% CI, 5.53-12.79). CONCLUSIONS Prolonged antimicrobial prophylaxis following CIED procedures increases preventable harm; this practice should be discouraged in procedural settings such as the cardiac electrophysiology laboratory.
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Real-world effectiveness of infection prevention interventions for reducing procedure-related cardiac device infections: Insights from the veterans affairs clinical assessment reporting and tracking program. Infect Control Hosp Epidemiol 2019; 40:855-862. [PMID: 31159895 DOI: 10.1017/ice.2019.127] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To measure the association between receipt of specific infection prevention interventions and procedure-related cardiac implantable electronic device (CIED) infections. DESIGN Retrospective cohort with manually reviewed infection status. SETTING Setting: National, multicenter Veterans Health Administration (VA) cohort. PARTICIPANTS Sampling of procedures entered into the VA Clinical Assessment Reporting and Tracking-Electrophysiology (CART-EP) database from fiscal years 2008 through 2015. METHODS A sample of procedures entered into the CART-EP database underwent manual review for occurrence of CIED infection and other clinical/procedural variables. The primary outcome was 6-month incidence of CIED infection. Measures of association were calculated using multivariable generalized estimating equations logistic regression. RESULTS We identified 101 procedure-related CIED infections among 2,098 procedures (4.8% of reviewed sample). Factors associated with increased odds of infections included (1) wound complications (adjusted odds ratio [aOR], 8.74; 95% confidence interval [CI], 3.16-24.20), (2) revisions including generator changes (aOR, 2.4; 95% CI, 1.59-3.63), (3) an elevated international normalized ratio (INR) >1.5 (aOR, 1.56; 95% CI, 1.12-2.18), and (4) methicillin-resistant Staphylococcus colonization (aOR, 9.56; 95% CI, 1.55-27.77). Clinically effective prevention interventions included preprocedural skin cleaning with chlorhexidine versus other topical agents (aOR, 0.41; 95% CI, 0.22-0.76) and receipt of β-lactam antimicrobial prophylaxis versus vancomycin (aOR, 0.60; 95% CI, 0.37-0.96). The use of mesh pockets and continuation of antimicrobial prophylaxis after skin closure were not associated with reduced infection risk. CONCLUSIONS These findings regarding the real-world clinical effectiveness of different prevention strategies can be applied to the development of evidence-based protocols and infection prevention guidelines specific to the electrophysiology laboratory.
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Branch-Elliman W, Pizer SD, Dasinger EA, Gold HS, Abdulkerim H, Rosen AK, Charns MP, Hawn MT, Itani KMF, Mull HJ. Facility type and surgical specialty are associated with suboptimal surgical antimicrobial prophylaxis practice patterns: a multi-center, retrospective cohort study. Antimicrob Resist Infect Control 2019; 8:49. [PMID: 30886702 PMCID: PMC6404270 DOI: 10.1186/s13756-019-0503-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 02/27/2019] [Indexed: 12/13/2022] Open
Abstract
Background Guidelines recommend discontinuation of antimicrobial prophylaxis within 24 h after incision closure in uninfected patients. However, how facility and surgical specialty factors affect the implementation of these evidence-based surgical prophylaxis guidelines in outpatient surgery is unknown. Thus, we sought to measure how facility complexity, including ambulatory surgical center (ASC) status and availability of ancillary services, impact adherence to guidelines for timely discontinuation of antimicrobial prophylaxis after outpatient surgery. A secondary aim was to measure the association between surgical specialty and guideline compliance. Methods A multi-center, national Veterans Health Administration retrospective cohort from 10/1/2015-9/30/2017 including any Veteran undergoing an outpatient surgical procedure in any of five specialties (general surgery, urology, ophthalmology, ENT, orthopedics) was created. The primary outcome was the association between facility complexity and proportion of surgeries not compliant with discontinuation of antimicrobials within 24 h of incision closure. Data were analyzed using logistic regression with adjustments for patient and procedural factors. Results Among 153,097 outpatient surgeries, 7712 (5.0%) received antimicrobial prophylaxis lasting > 24 h after surgery; rates ranged from 0.4% (eye surgeries) to 13.7% (genitourinary surgeries). Cystoscopies and cystoureteroscopy with lithotripsy procedures had the highest rates (16 and 20%), while hernia repair, cataract surgeries, and laparoscopic cholecystectomies had the lowest (0.2-0.3%). In an adjusted logistic regression model, lower complexity ASC and hospital outpatient departments had higher odds of prolonged antimicrobial prophylaxis compared to complex hospitals (OR ASC, 1.3, 95% CI: 1.2-1.5). Patient factors associated with higher odds of noncompliance with antimicrobial discontinuation included younger age, female sex, and white race. Genitourinary and ear/nose/throat surgeries were associated with the highest odds of prolonged antimicrobial prophylaxis. Conclusions Facility complexity appears to play a role in adherence to surgical infection prevention guidelines. Lower complexity facilities with limited infection prevention and antimicrobial stewardship resources may be important targets for quality improvement. Such interventions may be especially useful for genitourinary and ear/nose/throat surgical subspecialties. Increasing pharmacy, antimicrobial stewardship and/or infection prevention resources to promote more evidence-based care may support surgical providers in lower complexity ambulatory surgery centers and hospital outpatient departments in their efforts to improve this facet of patient safety.
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Affiliation(s)
- Westyn Branch-Elliman
- 1Department of Medicine, Section of Infectious Diseases, VA Boston Healthcare System, MA 1400 VFW Parkway West Roxbury, Boston, MA 02132 USA.,2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA.,3Harvard Medical School, 25 Shattuck Street Boston, Boston, MA 02115 USA
| | - Steven D Pizer
- 4Partnered Evidence-based Policy Resource Center (PEPReC), Department of Veterans Affairs, 150 South Huntington Avenue Boston, Boston, MA 02130 USA.,5Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118 USA
| | - Elise A Dasinger
- VA Quality Scholars Program, Birmingham VA Medical Center, Birmingham, 700 19th Street S, AL 35233 England
| | - Howard S Gold
- 3Harvard Medical School, 25 Shattuck Street Boston, Boston, MA 02115 USA.,7Beth Israel Deaconess Medical Center, Division of Infectious Diseases, 110 Francis Street, Boston, MA 02115 USA
| | - Hassen Abdulkerim
- 2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA
| | - Amy K Rosen
- 2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA.,8Department of Surgery, Boston University School of Medicine, 88 East Newton Street, C515, Boston, MA 02118 USA
| | - Martin P Charns
- 2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA
| | - Mary T Hawn
- 9Palo Alto VA Medical Center, 3801 Miranda Ave, Palo Alto, CA 95010 USA.,10Stanford University School of Medicine, 291 Campus Drive Stanford, Stanford, CA 94305 USA
| | - Kamal M F Itani
- 11Department of Surgery, VA Boston Healthcare System, 1400 VFW Parkway West Roxbury, Boston, MA 02132 USA.,3Harvard Medical School, 25 Shattuck Street Boston, Boston, MA 02115 USA.,8Department of Surgery, Boston University School of Medicine, 88 East Newton Street, C515, Boston, MA 02118 USA
| | - Hillary J Mull
- 2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA.,8Department of Surgery, Boston University School of Medicine, 88 East Newton Street, C515, Boston, MA 02118 USA
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Branch-Elliman W. A Roadmap for Reducing Cardiac Device Infections: a Review of Epidemiology, Pathogenesis, and Actionable Risk Factors to Guide the Development of an Infection Prevention Program for the Electrophysiology Laboratory. Curr Infect Dis Rep 2017; 19:34. [PMID: 28815459 DOI: 10.1007/s11908-017-0591-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Cardiovascular implantable electronic device (CIED) infections are highly morbid, common, and costly, and rates are increasing (Sohail et al. Arch Intern Med 171(20):1821-8 2011; Voigt et al. J Am Coll Cardiol 48(3):590-1 2006). Factors that contribute to the development of CIED infections include patient factors (comorbid conditions, self-care, microbiome), procedural details (repeat procedure, contamination during procedure, appropriate pre-procedural prep, and antimicrobial use), environmental and organizational factors (patient safety culture, facility barriers, such as lack of space to store essential supplies, quality of environmental cleaning), and microbial factors (type of organism, virulence of organism). Each of these can be specifically targeted with infection prevention interventions. RECENT FINDINGS Basic prevention practices, such as administration of systemic antimicrobials prior to incision and delaying the procedure in the setting of fever or elevated INR, are helpful for day-to-day prevention of cardiac device infections. Small single-center studies provide proof-of-concept that bundled prevention interventions can reduce infections, particularly in outbreak settings. However, data regarding which prevention strategies are the most important is limited as are data regarding the optimal prevention program for day-to-day prevention (Borer et al. Infect Control Hosp Epidemiol 25(6):492-7 2004; Ahsan et al. Europace 16(10):1482-9 2014). Evolution of infection prevention programs to include ambulatory and procedural areas is crucial as healthcare delivery is increasingly provided outside of hospitals and operating rooms. The focus on traditional operating rooms and inpatient care leaves the vast majority of healthcare delivery-including cardiac device implantations in the electrophysiology laboratory-uncovered.
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Affiliation(s)
- Westyn Branch-Elliman
- VA Boston Healthcare System, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
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Implementation of Infection Prevention and Antimicrobial Stewardship in Cardiac Electrophysiology Laboratories: Results from the SHEA Research Network. Infect Control Hosp Epidemiol 2017; 38:496-498. [PMID: 28103958 DOI: 10.1017/ice.2016.309] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Infection prevention in electrophysiology (EP) laboratories is poorly characterized; thus, we conducted a cross-sectional survey using the SHEA Research Network. We found limited uptake of basic interventions, such as surveillance and appropriate peri-procedural antimicrobial use. Further study is needed to identify ways to improve infection prevention in this setting.
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