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Hidad S, de Greeff SC, Haenen A, de Haan F, Leusink GL, Timen A. Mind the gap: knowledge, attitudes and perceptions on antimicrobial resistance, antimicrobial stewardship and infection prevention and control in long-term care facilities for people with disabilities in the Netherlands. Antimicrob Resist Infect Control 2024; 13:56. [PMID: 38835090 DOI: 10.1186/s13756-024-01415-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 05/28/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) has become one of the major public health threats worldwide, emphasizing the necessity of preventing the development and transmission of drug resistant microorganisms. This is particularly important for people with vulnerable health conditions, such as people with intellectual disabilities (ID) and long-term care residents. This study aimed to assess the current status of AMR, antimicrobial stewardship (AMS) and infection prevention and control (IPC) in Dutch long-term care facilities for people with intellectual disabilities (ID-LTCFs). METHODS A web-based cross-sectional survey distributed between July and November 2023, targeting (both nonmedically and medically trained) healthcare professionals working in ID-LTCFs in The Netherlands, to study knowledge, attitudes and perceptions regarding AMR, AMS and IPC. RESULTS In total, 109 participants working in 37 long-term care organizations for people with intellectual disabilities throughout the Netherlands completed the questionnaire. The knowledge levels of AMR and IPC among nonmedically trained professionals (e.g., social care professionals) were lower than those among medically trained professionals (p = 0.026). In particular regarding the perceived protective value of glove use, insufficient knowledge levels were found. Furthermore, there was a lack of easy-read resources and useful information regarding IPC and AMR, for both healthcare professionals as well as people with disabilities. The majority of the participants (> 90%) reported that AMR and IPC need more attention within the disability care sector, but paradoxically, only 38.5% mentioned that they would like to receive additional information and training about IPC, and 72.5% would like to receive additional information and training about AMR. CONCLUSION Although the importance of AMR and IPC is acknowledged by professionals working in ID-LTCFs, there is room for improvement in regards to appropriate glove use and setting-specific IPC and hygiene policies. As nonmedically trained professionals comprise most of the workforce within ID-LTCFs, it is also important to evaluate their needs. This can have a substantial impact on developing and implementing AMR, AMS and/or IPC guidelines and policies in ID-LTCFs.
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Affiliation(s)
- S Hidad
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - S C de Greeff
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - A Haenen
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - F de Haan
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - G L Leusink
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - A Timen
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
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Iversen AM, Hansen MB, Münster M, Kristensen B, Ellermann-Eriksen S. Hand hygiene compliance in nursing home wards: the effect of increased accessibility of alcohol-based hand rub. J Hosp Infect 2024; 147:206-212. [PMID: 38521416 DOI: 10.1016/j.jhin.2024.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Elderly nursing home residents are vulnerable to infection from micro-organisms. Hand hygiene is considered one of the most important measures to prevent transmission. AIM To determine the effect of increased accessibility to alcohol-based hand rub (ABHR) in nursing home wards by monitoring hand hygiene compliance (HHC) among healthcare workers (HCWs). METHODS An 11-month intervention study was conducted in a Danish six-ward nursing home. Data were collected using an automatic hand hygiene monitoring system (AHHMS). After a baseline period, one extra ABHR dispenser was placed in each of the 150 apartments. Baseline HHC was compared with the HHC during an immediate intervention period and a long-term intervention period. FINDINGS A total of 159 HCWs were included. The AHHMS registered 341,078 hand hygiene opportunities. Overall baseline HHC was 31% (95% confidence interval: 30-32). A significant +18% absolute immediate effect (first five months) (95% CI: 17-19; P < 0.0001) and +13 percentage points (95% CI: 11-14; P < 0.0001) long-term effect (another four months) were recorded. HCWs working day shifts and short-term employees had a higher baseline HHC than HCWs working evening/night shifts. However, HCWs working night shifts achieved the greatest long-term effect with a mean +27 percentage point difference (P < 0.0001). CONCLUSION Placing an additional ABHR dispenser strategically within staff workflow significantly increased HHC among HCWs, demonstrating a noteworthy effect. The study is the first to report the effect on nursing home dispenser accessibility as a single intervention and to show a significant unmet potential.
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Affiliation(s)
- A-M Iversen
- Department of Oncology, Aarhus University Hospital and Aarhus University, Denmark.
| | - M B Hansen
- Konduto ApS, Sani Nudge, Copenhagen, Denmark
| | | | - B Kristensen
- National Centre of Infection Control, Statens Serum Institut, Copenhagen, Denmark
| | - S Ellermann-Eriksen
- Department of Clinical Microbiology, Aarhus University Hospital and Aarhus University, Denmark
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Iversen AM, Hansen MB, Kristensen B, Ellermann-Eriksen S. Hand hygiene compliance in nursing home wards: The effects of feedback with lights on alcohol-based hand rub dispensers. Am J Infect Control 2024:S0196-6553(24)00160-3. [PMID: 38583777 DOI: 10.1016/j.ajic.2024.03.018] [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: 01/22/2024] [Revised: 03/26/2024] [Accepted: 03/26/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Hand hygiene (HH) among health care workers (HCWs) is crucial in preventing infections in nursing homes. However, HH compliance (HHC) among HCWs remains low. This study aimed to investigate the effect of feedback lights on HCWs' HHC. METHODS A 5-month interventional study was conducted in 3 wards in a nursing home in Denmark. During the intervention period, a green light with a smiley appeared on the alcohol-based hand rub (ABHR) dispensers when HCWs used the ABHR, acknowledging HCWs for using the ABHR. HHC was monitored using an automatic HH monitoring system (AHHMS). RESULTS A total of 64 HCWs were enrolled. The AHHMS collected 23,696 HH opportunities in apartments and dirty utility rooms. Overall, HHC in the apartments increased from 50% at baseline (95% CI: 48, 53) to 56% (95% CI: 54, 58) during the intervention. However, the increased HHC level was not sustained during follow-up. CONCLUSIONS The AHHMS enabled the assessment of the intervention. We found a significant effect of light-guided feedback in the apartments. However, the increased HHC was not sustained after the light was switched off.
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Affiliation(s)
- Anne-Mette Iversen
- Department of Oncology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark.
| | | | - Brian Kristensen
- National Center of Infection Control, Statens Serum Institut, Copenhagen, Denmark
| | - Svend Ellermann-Eriksen
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
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Dekker M, van Mansfeld R, Borgert M, Maaskant J, Paulus F, Seller A, Jongerden IP. The combined application of hand hygiene and non-sterile gloves by nurses in a tertiary hospital: a multi methods study. Antimicrob Resist Infect Control 2024; 13:23. [PMID: 38419094 PMCID: PMC10903006 DOI: 10.1186/s13756-024-01378-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 02/06/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND The application of hand hygiene (HH) and the use of non-sterile gloves (NSG) in daily care is highly intertwined. We aimed (1) to assess the combined application of HH and NSG among nurses and (2) to explore determinants that influence their ability to combine both measures in their care. METHODS In a multi-methods study, we combined direct observations of care episodes with semi-structured interviews with nurses in two affiliated university hospitals. Topics were based on Flottorp's checklist of determinants of practice. RESULTS In total, we observed 205 care episodes and interviewed 10 nurses. Observations revealed that the combination of NSG and HH was correctly applied in 19% of care episodes in which a single procedure was executed, and in 2% of care episodes in which multiple procedures were performed. From the interviews, we found determinants that influenced compliance, covered mainly by three out of seven of Flottorp's checklist domains. Nurses indicated that their knowledge of protocols was limited to HH and protocols were hardly ever actively consulted; visual reminders within their workplace were used as sources of information. Nurses' behavior was primarily influenced by their ability to operationalize this information and their ability to integrate both infection prevention measures into their care. The intention to apply and combine HH and NSG use was influenced by their risk assessment of cross-contamination, by the urge to self-protect and gut feeling. The feasibility to execute HH and NSG protocols is influenced by the urgency and the complexity of the care episode. CONCLUSIONS The combined correct application with HH and NSG measures by nurses is low. Nurses are instructed in a fragmented way while in the day to day care HH and NSG use are highly intertwined. Operationalization and simplification of infection prevention protocols, in which instructions on both infection prevention measures are fused, should be considered. Strategies to improve practice should consider the power of habit and nurses urge to self-protect.
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Affiliation(s)
- Mireille Dekker
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands.
| | - Rosa van Mansfeld
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Marjon Borgert
- Amsterdam UMC, Department of Intensive Care, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jolanda Maaskant
- Amsterdam UMC, Department of Internal Medicine, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Frederique Paulus
- Amsterdam UMC, Department of Intensive Care, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Annamarike Seller
- Department of Human Resources, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Research Center for Health Economics, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, Societal participation & Health, Amsterdam, the Netherlands
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Irene P Jongerden
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, De Boelelaan 1117, Amsterdam, The Netherlands
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Windle A, Marshall A, de la Perrelle L, Champion S, Ross PD, Harvey G, Davy C. Factors that influence the implementation of innovation in aged care: a scoping review. JBI Evid Implement 2023; 22:02205615-990000000-00072. [PMID: 38153118 PMCID: PMC11163893 DOI: 10.1097/xeb.0000000000000407] [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: 12/29/2023]
Abstract
OBJECTIVE The objective of this scoping review is to identify factors that influence the implementation of innovation in aged care. INTRODUCTION Aged care is a dynamic sector experiencing rapid change. Implementation of innovations in aged care has received relatively little research attention compared to health care. INCLUSION CRITERIA This review included studies of any design, that examined the implementation of innovations in aged care settings. METHODS Searches were conducted in MEDLINE, CINAHL, AgeLine, and ProQuest Social Sciences Premium Collection for studies published between January 1, 2012 and December 31, 2022. The titles and abstracts of retrieved citations were screened by two independent reviewers. Full-text articles were screened by one reviewer to determine inclusion. Data were extracted in NVivo using a tool developed by the research team. Factors that influenced implementation were inductively coded, interpreted, and grouped into categories in a series of workshops. RESULTS Of the 2530 studies that were screened, 193 were included. Of the included papers, the majority (74%) related to residential aged care, 28% used an implementation theory or framework, and 15% involved consumers. Five key categories of factors influencing implementation were identified: organizational context including resourcing and culture; people's attitudes and capabilities; relationships between people; the intervention and its appropriateness; and implementation actions such as stakeholder engagement and implementation strategies. CONCLUSIONS Our findings can be used to develop practical resources to support implementation efforts, and highlight the importance of resourcing for successful implementation. Attention to community-based aged care, and greater engagement with theory and community is needed to promote research rigor, relevance and applicability.
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Affiliation(s)
- Alice Windle
- Aged Care Research and Industry Innovation Australia (ARIIA), Adelaide, SA, Australia
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Amy Marshall
- Aged Care Research and Industry Innovation Australia (ARIIA), Adelaide, SA, Australia
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
- Caring Futures Institute, Flinders University, Adelaide, SA, Australia
| | - Lenore de la Perrelle
- Aged Care Research and Industry Innovation Australia (ARIIA), Adelaide, SA, Australia
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Stephanie Champion
- Aged Care Research and Industry Innovation Australia (ARIIA), Adelaide, SA, Australia
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
- Caring Futures Institute, Flinders University, Adelaide, SA, Australia
| | - Paul D.S. Ross
- Aged Care Research and Industry Innovation Australia (ARIIA), Adelaide, SA, Australia
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Gillian Harvey
- Aged Care Research and Industry Innovation Australia (ARIIA), Adelaide, SA, Australia
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
- Caring Futures Institute, Flinders University, Adelaide, SA, Australia
| | - Carol Davy
- Aged Care Research and Industry Innovation Australia (ARIIA), Adelaide, SA, Australia
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
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Aebi NJ, Baenteli I, Fink G, Meinlschmidt G, Schaefert R, Schwenkglenks M, Studer A, Trost S, Tschudin S, Wyss K. Facilitators and barriers of routine psychosocial distress assessment within a stepped and collaborative care model in a Swiss hospital setting. PLoS One 2023; 18:e0285395. [PMID: 37390066 PMCID: PMC10313032 DOI: 10.1371/journal.pone.0285395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 04/24/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Stepped and Collaborative Care Models (SCCMs) have shown potential for improving mental health care. Most SCCMs have been used in primary care settings. At the core of such models are initial psychosocial distress assessments commonly in form of patient screening. We aimed to assess the feasibility of such assessments in a general hospital setting in Switzerland. METHODS We conducted and analyzed eighteen semi-structured interviews with nurses and physicians involved in a recent introduction of a SCCM model in a hospital setting, as part of the SomPsyNet project in Basel-Stadt. Following an implementation research approach, we used the Tailored Implementation for Chronic Diseases (TICD) framework for analysis. The TICD distinguishes seven domains: guideline factors, individual healthcare professional factors, patient factors, professional interactions, incentives and resources, capacity for organizational change, and social, political, and legal factors. Domains were split into themes and subthemes, which were used for line-by-line coding. RESULTS Nurses and physicians reported factors belonging to all seven TICD domains. An appropriate integration of the psychosocial distress assessment into preexisting hospital processes and information technology systems was the most important facilitator. Subjectivity of the assessment, lack of awareness about the assessment, and time constraints, particularly among physicians, were factors undermining and limiting the implementation of the psychosocial distress assessment. CONCLUSIONS Awareness raising through regular training of new employees, feedback on performance and patient benefits, and working with champions and opinion leaders can likely support a successful implementation of routine psychosocial distress assessments. Additionally, aligning psychosocial distress assessments with workflows is essential to assure the sustainability of the procedure in a working context with commonly limited time.
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Affiliation(s)
- Nicola Julia Aebi
- Swiss Center for International Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Iris Baenteli
- Department of Psychosomatic Medicine, University Hospital and University of Basel, Basel, Switzerland
| | - Günther Fink
- University of Basel, Basel, Switzerland
- Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Gunther Meinlschmidt
- Department of Psychosomatic Medicine, University Hospital and University of Basel, Basel, Switzerland
- Division of Clinical Psychology and Cognitive Behavioural Therapy, International Psychoanalytic University Berlin, Berlin, Germany
- Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland
| | - Rainer Schaefert
- Department of Psychosomatic Medicine, University Hospital and University of Basel, Basel, Switzerland
| | | | - Anja Studer
- Division of Prevention, Department of Health Canton Basel-Stadt, Basel, Switzerland
| | - Sarah Trost
- Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland
| | - Sibil Tschudin
- Department of Obstetrics and Gynecology, University Hospital and University of Basel, Basel, Switzerland
| | - Kaspar Wyss
- Swiss Center for International Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
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Haenen A, de Greeff S, Voss A, Liefers J, Hulscher M, Huis A. Hand hygiene compliance and its drivers in long-term care facilities; observations and a survey. Antimicrob Resist Infect Control 2022; 11:50. [PMID: 35303941 PMCID: PMC8931571 DOI: 10.1186/s13756-022-01088-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/25/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hand hygiene is an important measure to prevent healthcare-associated infections in long-term care facilities.
Objectives
To evaluate compliance with hand hygiene recommendations by different nursing professionals in long-term care facilities and to investigate determinants potentially influencing hand hygiene and whether these differed between the different cadres of staff.
Methods
We conducted two sub-studies: we measured hand hygiene compliance of 496 professionals in 14 long-term care facilities (23 wards) through direct observation using World Health Organisation’s ‘five moments of hand hygiene’ observation tool. In addition, we performed a survey to examine determinants that may influence hand hygiene and to determine differences between different cadres of staff. We used a principal component analysis approach with varimax rotation to explore the underlying factor structure of the determinants.
Results
We found an overall mean hand hygiene compliance of 17%. There was considerable variation between wards (5–38%) and between specific World Health Organization hand hygiene moments. In addition, hand hygiene compliance varied widely within and between different cadres of staff. The determinant analysis was conducted on 177 questionnaires. For all nursing professionals, we found multiple determinants in four domains: ‘social context and leadership’, ‘resources’, ‘individual healthcare professional factors’ and ‘risk perception’. In two domains, several barriers were perceived differently by nursing assistants and nurses. In the domain ‘social context and leadership’, this included (1) how the manager addresses barriers to enable hand hygiene as recommended and (2) how the manager pays attention to correct adherence to the hand hygiene guidelines. In the ‘risk perception’ domain, this included a resident's risk of acquiring an infection as a result of the nursing professional’s failure to comply with the hand hygiene guidelines.
Conclusion
Hand hygiene compliance was low and influenced by multiple factors, several of which varied among different cadres of staff. When designing interventions to improve hand hygiene performance in long-term care facilities, strategies should take into account these determinants and how they vary between different cadres of staff. We recommend exploring hand hygiene determinants at ward level and among different cadres of staff, for example by using our exploratory questionnaire.
Trial registration
Registration number 50-53000-98-113, ‘Compliance with hand hygiene in nursing homes: go for a sustainable effect’ on ClinicalTrials.gov. Date of registration 28-6-2016.
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Haverhals LM, Magid KH, Kononowech J. Applying the Tailored Implementation in Chronic Diseases framework to inform implementation of the Preferences Elicited and Respected for Seriously Ill Veterans through enhanced decision-making program in the United States Veterans Health Administration. FRONTIERS IN HEALTH SERVICES 2022; 2:935341. [PMID: 36925825 PMCID: PMC10012641 DOI: 10.3389/frhs.2022.935341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022]
Abstract
In 2017, the National Center for Ethics in Health Care for the United States Department of Veterans Affairs (VA) commenced national roll-out of the Life-Sustaining Treatment Decisions Initiative. This national VA initiative aimed to promote personalized, proactive, patient-driven care for seriously ill Veterans by documenting Veterans' goals and preferences for life-sustaining treatments in a durable electronic health record note template known as the life-sustaining treatment template. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) quality improvement program was created to address the high variation in life-sustaining treatment template completion in VA Home Based Primary Care (HBPC) and Community Nursing Home programs. This manuscript describes the program that focuses on improving life sustaining treatment template completion rates amongst HBPC programs. To increase life-sustaining treatment template completion for Veterans receiving care from HBPC programs, the PERSIVED team applies two implementation strategies: audit with feedback and implementation facilitation. The PERSIVED team conducts semi-structured interviews, needs assessments, and process mapping with HBPC programs in order to identify barriers and facilitators to life-sustaining treatment template completion to inform tailored facilitation. Our interview data is analyzed using the Tailored Implementation in Chronic Diseases (TICD) framework, which identifies 57 determinants that might influence practice or implementation of interventions. To quickly synthesize and use baseline data to inform the tailored implementation plan, we adapted a rapid analysis process for our purposes. This paper describes a six-step process for conducting and analyzing baseline interviews through applying the TICD that can be applied and adapted by implementation scientists to rapidly inform tailoring of implementation facilitation.
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Affiliation(s)
- Leah M Haverhals
- Denver-Seattle VA Center of Innovation for Value Driven and Veteran-Centric Care, Rocky Mountain Regional VA Medical Center at VA Eastern Colorado Health Care System, Aurora, CO, United States.,Health Care Policy and Research, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kate H Magid
- Denver-Seattle VA Center of Innovation for Value Driven and Veteran-Centric Care, Rocky Mountain Regional VA Medical Center at VA Eastern Colorado Health Care System, Aurora, CO, United States
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