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Smith M, Crnich C, Donskey C, Evans CT, Evans M, Goto M, Guerrero B, Gupta K, Harris A, Hicks N, Khader K, Kralovic S, McKinley L, Rubin M, Safdar N, Schweizer ML, Tovar S, Wilson G, Zabarsky T, Perencevich EN. Research agenda for transmission prevention within the Veterans Health Administration, 2024-2028. Infect Control Hosp Epidemiol 2024:1-10. [PMID: 38600795 DOI: 10.1017/ice.2024.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Matthew Smith
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Chris Crnich
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
| | - Curtis Donskey
- Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA
- Department of Preventive Medicine and Center for Health Services and Outcomes Research, Northwestern University of Feinberg School of Medicine, Chicago, IL, USA
| | - Martin Evans
- MRSA/MDRO Division, VHA National Infectious Diseases Service, Patient Care Services, VA Central Office and the Lexington VA Health Care System, Lexington, KY, USA
| | - Michihiko Goto
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Bernardino Guerrero
- Environmental Programs Service (EPS), Veterans Affairs Central Office, Washington, DC, USA
| | - Kalpana Gupta
- VA Boston Healthcare System and Boston University School of Medicine, Boston, MA, USA
| | - Anthony Harris
- Department of Epidemiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Natalie Hicks
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
| | - Karim Khader
- DEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Stephen Kralovic
- Veterans Health Administration National Infectious Diseases Service, Washington, DC, USA
- Cincinnati VA Medical Center and University of Cincinnati, Cincinnati, OH, USA
| | - Linda McKinley
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
| | - Michael Rubin
- DEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Nasia Safdar
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
| | - Marin L Schweizer
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, and William S. Middleton Hospital, Madison, WI, USA
| | - Suzanne Tovar
- National Infectious Diseases Service (NIDS), Veterans Affairs Central Office, Washington, DC, USA
| | - Geneva Wilson
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines Jr. Veterans Affairs Hospital, Hines, IL, USA
- Department of Preventive Medicine, Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Trina Zabarsky
- Environmental Programs Service (EPS), Veterans Affairs Central Office, Washington, DC, USA
| | - Eli N Perencevich
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Livorsi DJ, Branch-Elliman W, Drekonja D, Echevarria KL, Fitzpatrick MA, Goetz MB, Graber CJ, Jones MM, Kelly AA, Madaras-Kelly K, Morgan DJ, Stevens VW, Suda K, Trautner BW, Ward MJ, Jump RLP. Research agenda for antibiotic stewardship within the Veterans' Health Administration, 2024-2028. Infect Control Hosp Epidemiol 2024:1-7. [PMID: 38305034 PMCID: PMC11294492 DOI: 10.1017/ice.2024.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Affiliation(s)
- Daniel J Livorsi
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans' Affairs (VA) Health Care System, Iowa City, Iowa
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Westyn Branch-Elliman
- VA Boston Healthcare System, Department of Medicine, Section of Infectious Diseases. Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Dimitri Drekonja
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kelly L Echevarria
- VHA Pharmacy Benefits and Antimicrobial Stewardship Task Force, Department of Veterans' Affairs, Washington, DC
| | - Margaret A Fitzpatrick
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Christopher J Graber
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Makoto M Jones
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Allison A Kelly
- VHA Pharmacy Benefits and Antimicrobial Stewardship Task Force, Department of Veterans' Affairs, Washington, DC
- Cincinnati Veterans' Affairs Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Karl Madaras-Kelly
- Boise Veterans' Affairs Medical Center, Boise, Idaho
- Idaho State University, College of Pharmacy, Meridian, Idaho
| | - Daniel J Morgan
- Department of Medicine, VA Maryland Healthcare System, Baltimore, Maryland
- Center for Innovation in Diagnosis, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vanessa W Stevens
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Katie Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans' Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Michael J Ward
- Geriatric Research, Education, and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee
- Department of Emergency Medicine and Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robin L P Jump
- Technology Enhancing Cognition and Health Geriatric Research Education and Clinical Center (TECH-GRECC) at the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Gillespie C, Sitter K, McConeghy KW, Strymish J, Gupta K, Hartmann CW, Borzecki AM. Facilitators and Barriers to Verifying Penicillin Allergies in a Veteran Nursing Home Population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2848-2854.e3. [PMID: 37352930 DOI: 10.1016/j.jaip.2023.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Unconfirmed penicillin allergies are common and may contribute to adverse outcomes, especially in frail older patients. Evidence-based clinical pathways for evaluating penicillin allergies have been effectively and safely applied in selected settings, but not in nursing home populations. OBJECTIVE To identify potential facilitators and barriers to implementing a strategy to verify penicillin allergies in Veterans Health Administration nursing homes, known as Community Living Centers (CLCs). METHODS We conducted semistructured interviews with staff, patients, and family members at 1 CLC to assess their understanding of penicillin allergies and receptiveness to verifying the allergy. We also asked staff about the proposed allergy assessment strategy, including willingness to delabel by history and feasibility of performing oral challenges or skin testing on their unit. RESULTS From 24 interviews (11 front-line staff, 4 leadership, 3 patients, 6 family members), we identified several facilitators or barriers. Staff recognized the importance of allergy verification and were willing to support and assist in implementing verification strategies. The CLC residents were willing to have their allergy status verified. However, some family members expressed reluctance to verifying their relative's allergy status owing to safety concerns. Front-line staff also expressed concern over having the necessary resources, including time and expertise, to implement the strategy. Staff suggested involving clinical pharmacists and educating staff, patients, and family members as ways to overcome these barriers. CONCLUSIONS Concerns about safety and staff resources are important potential barriers to implementing verification strategies. Involvement of pharmacists and education of both staff and patients and family members will be important components of any successful intervention.
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Affiliation(s)
- Chris Gillespie
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass.
| | - Kailyn Sitter
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass
| | - Kevin W McConeghy
- Center of Innovation in Long-Term Services and Supports, Veterans Administration Medical Center, Providence, RI; Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI
| | - Judith Strymish
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of Infectious Diseases, VA Boston Healthcare System, Boston, Mass
| | - Kalpana Gupta
- Division of Infectious Diseases, VA Boston Healthcare System, Boston, Mass; Center for Healthcare Organization and Implementation Research (CHOIR), Boston Campus, VA Boston Healthcare System, Boston, Mass; Department of General Internal Medicine, Boston University School of Medicine, Boston, Mass
| | - Christine W Hartmann
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass; Zuckerberg College of Health Sciences, Department of Public Health, University of Massachusetts Lowell, Lowell, Mass
| | - Ann M Borzecki
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass; Department of General Internal Medicine, Boston University School of Medicine, Boston, Mass; School of Public Health, Department of Health Law, Policy and Management, Boston University School of Public Health, Boston University, Boston, Mass
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Jones D, Marra AR, Livorsi D, Perencevich E, Goto M. Perceptions of an automated benchmarking dashboard for antimicrobial stewardship programs among antimicrobial stewards within the veterans' health administration: a multicenter qualitative study. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e118. [PMID: 37502245 PMCID: PMC10369443 DOI: 10.1017/ash.2023.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 07/29/2023]
Abstract
Objective To evaluate the impact of a multicenter, try automated dashboard on ASP activities and its acceptance among ASP leaders. Design Frontline stewards were asked to participate in semi-structured interviews before and after implementation of a web-based ASP information dashboard providing risk-adjusted benchmarking, longitudinal trends, and analysis of antimicrobial usage patterns at each facility. Setting The study was performed at Iowa City VA Health Care System. Participants ASP team members from nine medical centers in the VA Midwest Health Care Network (VISN 23). Methods Semi-structured interviews were conducted pre- and post-implementation, with interview guides informed by clinical experiences and the Consolidated Framework for Implementation Research (CFIR). Participants evaluated the dashboard's ease of use, applicability to ongoing ASP activities, perceived validity and reliability, and relative advantage over other ASP monitoring systems. Results Compared to established stewardship data collection and reporting methods, participants found the dashboard more intuitive and accessible, allowing them to reduce dependence on other systems and staff to obtain and share data. Standardized and risk-adjusted rankings were largely accepted as a valuable benchmarking method; however, participants felt their facility's characteristics significantly influenced the rankings' validity. Participants recognized staffing, training, and uncertainty with using the dashboard as an intervention tool as barriers to consistent and comprehensive dashboard implementation. Conclusions Participants generally accepted the dashboard's risk-adjusted metrics and appreciated its usability. While creating automated tools to rigorously benchmark antimicrobial use across hospitals can be helpful, the displayed metrics require further validation, and the longitudinal utility of the dashboard warrants additional study.
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Affiliation(s)
- DeShauna Jones
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- University of Iowa, Institute for Clinical and Translational Science, Iowa City, IA, USA
| | - Alexandre R. Marra
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- University of Iowa, Carver College of Medicine, Iowa City, IA, USA
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Daniel Livorsi
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- University of Iowa, Carver College of Medicine, Iowa City, IA, USA
| | - Eli Perencevich
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- University of Iowa, Carver College of Medicine, Iowa City, IA, USA
| | - Michihiko Goto
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- University of Iowa, Carver College of Medicine, Iowa City, IA, USA
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Evaluation of antibiotic prescribing in emergency departments and urgent care centers across the Veterans' Health Administration. Infect Control Hosp Epidemiol 2020; 42:694-701. [PMID: 33308352 DOI: 10.1017/ice.2020.1289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Assessments of antibiotic prescribing in ambulatory care have largely focused on viral acute respiratory infections (ARIs). It is unclear whether antibiotic prescribing for bacterial ARIs should also be a target for antibiotic stewardship efforts. In this study, we evaluated antibiotic prescribing for viral and potentially bacterial ARIs in patients seen at emergency departments (EDs) and urgent care centers (UCCs). DESIGN This retrospective cohort included all ED and UCC visits by patients who were not hospitalized and were seen during weekday, daytime hours during 2016-2018 in the Veterans Health Administration (VHA). Guideline concordance was evaluated for viral ARIs and for 3 potentially bacterial ARIs: acute exacerbation of COPD, pneumonia, and sinusitis. RESULTS There were 3,182,926 patient visits across 129 sites: 80.7% in EDs and 19.3% in UCCs. Mean patient age was 60.2 years, 89.4% were male, and 65.6% were white. Antibiotics were prescribed during 608,289 (19.1%) visits, including 42.7% with an inappropriate indication. For potentially bacterial ARIs, guideline-concordant management varied across clinicians (median, 36.2%; IQR, 26.0-52.7) and sites (median, 38.2%; IQR, 31.7-49.4). For viral ARIs, guideline-concordant management also varied across clinicians (median, 46.2%; IQR, 24.1-68.6) and sites (median, 40.0%; IQR, 30.4-59.3). At the clinician and site levels, we detected weak correlations between guideline-concordant management for viral ARIs and potentially bacterial ARIs: clinicians (r = 0.35; P = .0001) and sites (r = 0.44; P < .0001). CONCLUSIONS Our findings suggest that, across EDs and UCCs within VHA, there are major opportunities to improve management of both viral and potentially bacterial ARIs. Some clinicians and sites are more frequently adhering to ARI guideline recommendations on antibiotic use.
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Ramakrishnan A, Patel PK. How Far We've Come, How Far We Have to Go: a Review of Advances in Antimicrobial Stewardship in the Veterans Health Administration. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020; 12:275-284. [PMID: 33244296 PMCID: PMC7688065 DOI: 10.1007/s40506-020-00221-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW This review highlights several of the successes in antimicrobial stewardship seen in the largest integrated healthcare system in the USA, the Veterans Health Administration. RECENT FINDINGS Since deploying antimicrobial stewardship programs on a national scale in the Veterans Health Administration, decreases in overall antimicrobial use and Clostridioides difficile infections have been observed. Concurrent infection prevention initiatives have also contributed to these improvements in the Veterans Health Administration. SUMMARY By embracing multidisciplinary stewardship teams, focusing on education and research in the field of antimicrobial stewardship, and leveraging the vast data available within the national system, the Veterans Health Administration has made substantial advances in antimicrobial stewardship.
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Affiliation(s)
- Aditi Ramakrishnan
- Division of Infectious Diseases, Emory University School of Medicine, 49 Jesse Hill Jr. Drive, Atlanta, GA, 30303, USA
| | - Payal K. Patel
- Division of Infectious Diseases, Ann Arbor VA Healthcare System and the University of Michigan Medical School, Ann Arbor, MI, USA
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Wattengel BA, Sellick JA, Mergenhagen KA. Outpatient antimicrobial stewardship: Optimizing patient care via pharmacist led microbiology review. Am J Infect Control 2020; 48:189-193. [PMID: 31492553 DOI: 10.1016/j.ajic.2019.07.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/23/2019] [Accepted: 07/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Cultures are often taken in the outpatient setting but results are not acted upon, leading to unnecessary re-presentations to the health care setting. METHODS This study was a prospective study with interventions made between January 1, 2018, and January 1, 2019. Cultures were reviewed to ensure appropriate antimicrobial coverage. The objective was to compare outcomes with accepted versus rejected interventions. Descriptive statistics were used to summarize data. RESULTS A total of 7,360 antibiotic orders were reviewed by the infectious diseases pharmacists. Pharmacists intervened on 20.1% (n = 194) of encounters with related cultures. Interventions were most frequent in the emergency department (42%). Ciprofloxacin required the most interventions (26%), followed by third-generation cephalosporins (22%). The intervention acceptance rate was 76%, which was associated with decreased rates of 30-day treatment failure (5% vs 28%, P < .001) and 30-day admission (0.7% vs 11%, P = .001), when interventions were accepted rather than rejected. DISCUSSION Approximately 20% of patients required intervention. Culture review services may be beneficial in a variety of outpatient settings. Outpatient stewardship literature is limited, and our study found a decrease in admission and treatment failure. CONCLUSIONS Microbiology review and intervention positively impacted care for outpatients. Intervention was associated with significantly decreased rates of treatment failure and admission when interventions were accepted.
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Abstract
Antimicrobial stewardship improves patient care and reduces antimicrobial resistance, inappropriate use, and adverse outcomes. Despite high-profile mandates for antimicrobial stewardship programs across the healthcare continuum, descriptive data, and recommendations for dedicated resources, including appropriate physician, pharmacist, data analytics, and administrative staffing support, are not robust. This review summarizes the current literature on antimicrobial stewardship staffing and calls for the development of minimum staffing recommendations.
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