Educational Audit Research Articles

Sustainability of healthcare professionals\u2019 adherence to clinical practice guidelines in primary care

BackgroundSustainability of adherence to clinical practice guidelines (CPGs) represents an important indicator of the successful implementation in the primary care setting.AimTo explore the sustainability of primary care providers’ adherence to CPGs after receiving planned guideline implementation strategies, activities, or programmes.MethodsCochrane Central Register of Controlled Trials (CENTRAL); Cumulative Index to Nursing and Allied Health Literature (CINAHL); EMBase; Joanna Briggs Institute; Journals@Ovid; Medline; PsycoINFO; PubMed, and Web of Science were searched from January 2000 through May 2021 to identify relevant studies. Studies evaluating the sustainability of primary care providers’ (PCPs’) adherence to CPGs in primary care after any planned guideline implementation strategies, activities, or programmes were included. Two reviewers extracted data from the included studies and assessed methodological quality independently. Narrative synthesis of the findings was conducted.ResultsEleven studies were included. These studies evaluated the sustainability of adherence to CPGs related to drug prescribing, disease management, cancer screening, and hand hygiene in primary care. Educational outreach visits, teaching sessions, reminders, audit and feedback, and printed materials were utilized in the included studies as guideline implementation strategies. None of the included studies utilized purpose-designed measurements to evaluate the extent of sustainability. Three studies showed positive sustainability results, three studies showed mixed sustainability results, and four studies reported no significant changes in the sustainability of adherence to CPGs. Overall, it was difficult to quantify the extent to which CPG-based healthcare behaviours were fully sustained based on the variety of results reported in the included studies.ConclusionCurrent guideline implementation strategies may potentially improve the sustainability of PCPs’ adherence to CPGs. However, the literature reveals a limited body of evidence for any given guideline implementation strategy. Further research, including the development of a validated purpose-designed sustainability tool, is required to address this important clinical issue.Trial registrationThe study protocol has been registered at PROSPERO (No. CRD42021259748).

Guidance or Gatekeeping: An Audit Examination of Racial Discrimination in Leading STEM High Schools: Systems that Marginalize BIPOC Youth Special Issue: Dismantling Oppression Series: Systems that Marginalize BIPOC Youth Special Issue: Dismantling Oppression Series.

Racial discrimination remains a mechanism by which ethnic-racial minorities are restricted from power. We examined whether racial discrimination restricts ethnic-racial minority access to high-achieving STEM schools. We conducted an audit correspondence experiment to investigate racial discrimination in guidance counselor responsiveness to 976 emails from fictitious Asian, Black, Latina, and White mothers inquiring about school enrollment. Moderation analyses revealed that guidance counselors restricted access from Asian mothers at schools characterized as rural, lower socioeconomic status, and higher STEM prestige-evidence of gatekeeping points to the restriction of Asian students from advanced STEM opportunities. Results are situated within educational audit experiments to objectively document how racism from multiple facets of the education system intersect to inhibit ethnic-racial minority youth.

Increased adherence to perioperative safety guidelines associated with improved patient safety outcomes: a stepped-wedge, cluster-randomised multicentre trial

BackgroundNational Dutch guidelines have been introduced to improve suboptimal perioperative care. A multifaceted implementation programme (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) has been developed to support hospitals in applying these guidelines. This study evaluated the effectiveness of IMPROVE on guideline adherence and the association between guideline adherence and patient safety. MethodsNine hospitals participated in this unblinded, superiority, stepped-wedge, cluster RCT in patients with major noncardiac surgery (mortality risk ≥1%). IMPROVE consisted of educational activities, audit and feedback, reminders, organisational, team-directed, and patient-mediated activities. The primary outcome of the study was guideline adherence measured by nine patient safety indicators on the process (stop moments from the composite STOP bundle, and timely administration of antibiotics) and on the structure of perioperative care. Secondary safety outcomes included in-hospital complications, postoperative wound infections, mortality, length of hospital stay, and unplanned care. ResultsData were analysed for 1934 patients. The IMPROVE programme improved one stop moment: ‘discharge from recovery room’ (+16%; 95% confidence interval [CI], 9–23%). This stop moment was related to decreased mortality (–3%; 95% CI, –4% to –1%), fewer complications (–8%; 95% CI, –13% to –3%), and fewer unscheduled transfers to the ICU (–6%; 95% CI, –9% to –3%). IMPROVE negatively affected one other stop moment – ‘discharge from the hospital’ – possibly because of the limited resources of hospitals to improve all stop moments together. ConclusionsMixed implementation effects of IMPROVE were found. We found some positive associations between guideline adherence and patient safety (i.e. mortality, complications, and unscheduled transfers to the ICU) except for the timely administration of antibiotics. Clinical trial registrationNTR3568 (Dutch Trial Registry).

Implementation and Evaluation of a Digitally Enabled Precision Public Health Intervention to Reduce Inappropriate Gabapentinoid Prescription: Cluster Randomized Controlled Trial.

BackgroundDigital technologies can enable rapid targeted delivery of audit and feedback interventions at scale. Few studies have evaluated how mode of delivery affects clinical professional behavior change and none have assessed the feasibility of such an initiative at a national scale.ObjectiveThe aim of this study was to develop and evaluate the effect of audit and feedback by digital versus postal (letter) mode of delivery on primary care physician behavior.MethodsThis study was developed as part of the Veterans’ Medicines Advice and Therapeutics Education Services (MATES) program, an intervention funded by the Australian Government Department of Veterans’ Affairs that provides targeted education and patient-specific audit with feedback to Australian general practitioners, as well as educational material to veterans and other health professionals. We performed a cluster randomized controlled trial of a multifaceted intervention to reduce inappropriate gabapentinoid prescription, comparing digital and postal mode of delivery. All veteran patients targeted also received an educational intervention (postal delivery). Efficacy was measured using a linear mixed-effects model as the average number of gabapentinoid prescriptions standardized by defined daily dose (individual level), and number of veterans visiting a psychologist in the 6 and 12 months following the intervention.ResultsThe trial involved 2552 general practitioners in Australia and took place in March 2020. Both intervention groups had a significant reduction in total gabapentinoid prescription by the end of the study period (digital: mean reduction of 11.2%, P=.004; postal: mean reduction of 11.2%, P=.001). We found no difference between digital and postal mode of delivery in reduction of gabapentinoid prescriptions at 12 months (digital: –0.058, postal: –0.058, P=.98). Digital delivery increased initiations to psychologists at 12 months (digital: 3.8%, postal: 2.0%, P=.02).ConclusionsOur digitally delivered professional behavior change intervention was feasible, had comparable effectiveness to the postal intervention with regard to changes in medicine use, and had increased effectiveness with regard to referrals to a psychologist. Given the logistical benefits of digital delivery in nationwide programs, the results encourage exploration of this mode in future interventions.

Central venous catheter access and procedure compliance: A qualitative interview study exploring intensive care nurses’ experiences

ObjectiveTo explore intensive care nurses’ experiences with and perceptions of using a standardised central venous catheter procedure to prevent bacterial contamination when accessing patients’ central venous catheters. Design and methodologyThis study employed an interpretative qualitative design. Data was collected through semi-structured, individual interviews and Qualitative Content Analysis was used in data analysis. SettingSeven Norwegian intensive care nurses were recruited using a purposeful sampling strategy. FindingsThree main themes were identified. 1). Individualised practice revealed varying knowledge of and commitment to following the central line procedure. 2). Risk desensitisation revealed a continuous use of central lines, acute situations and a lack of information on infections, which affect usage. 3). Professional working culture showed nurse-to-nurse interaction, which promoted compliance with the procedure. Their interplay created a team spirit whereby nurses worked together to improve patient safety. ConclusionsThis study shows the diversity and complexity of factors affecting intensive care nurses’ procedure compliance when accessing central lines. The themes of Individualised practice and Risk desensitisation pose a substantial threat to healthcare quality and patient safety in the ICU. Exposure to infection risks could be reduced by applying these themes to inform and strengthen continuing education programs and audit processes. The theme of Professional working culture shows the positive influence nurses can have on each other, promoting compliance when accessing central lines. Intensive care nurses should be aware that their voice matters and that challenging poor practice does not have to be confrontational. Leadership should look for ways to encourage this type of nurse-to-nurse interaction.

Process evaluation of a cluster randomised controlled trial to improve bronchiolitis management \u2013 a PREDICT mixed-methods study

BackgroundBronchiolitis is the most common reason for hospitalisation in infants. All international bronchiolitis guidelines recommend supportive care, yet considerable variation in practice continues with infants receiving non-evidence based therapies. We developed six targeted, theory-informed interventions; clinical leads, stakeholder meeting, train-the-trainer, education delivery, other educational materials, and audit and feedback. A cluster randomised controlled trial (cRCT) found the interventions to be effective in reducing use of five non-evidence based therapies in infants with bronchiolitis. This process evaluation paper aims to determine whether the interventions were implemented as planned (fidelity), explore end-users’ perceptions of the interventions and evaluate cRCT outcome data with intervention fidelity data.MethodsA pre-specified mixed-methods process evaluation was conducted alongside the cRCT, guided by frameworks for process evaluation of cRCTs and complex interventions. Quantitative data on the fidelity, dose and reach of interventions were collected from the 13 intervention hospitals during the study and analysed using descriptive statistics. Qualitative data identifying perception and acceptability of interventions were collected from 42 intervention hospital clinical leads on study completion and analysed using thematic analysis.ResultsThe cRCT found targeted, theory-informed interventions improved bronchiolitis management by 14.1%. The process evaluation data found variability in how the intervention was delivered at the cluster and individual level. Total fidelity scores ranged from 55 to 98% across intervention hospitals (mean = 78%; SD = 13%). Fidelity scores were highest for use of clinical leads (mean = 98%; SD = 7%), and lowest for use of other educational materials (mean = 65%; SD = 19%) and audit and feedback (mean = 65%; SD = 20%). Clinical leads reflected positively about the interventions, with time constraints being the greatest barrier to their use.ConclusionOur targeted, theory-informed interventions were delivered with moderate fidelity, and were well received by clinical leads. Despite clinical leads experiencing challenges of time constraints, the level of fidelity had a positive effect on successfully de-implementing non-evidence-based care in infants with bronchiolitis. These findings will inform widespread rollout of our bronchiolitis interventions, and guide future practice change in acute care settings.Trial registrationAustralian and New Zealand Clinical Trials Registry: ACTRN12616001567415.

Children\u2019s palliative care education and training: developing an education standard framework and audit

BackgroundThe need to align the range of guidance and competencies concerning children’s palliative care and develop an education framework have been recommended by a UK All-Party Parliament Group and others. In response to these recommendations the need for a revised children’s palliative care competency framework was recognized. A Children’s Palliative Care Education and Training Action Group, comprising champions in the field, was formed across UK and Ireland in 2019 to take this work forward. Their aim was to agree core principles of practice in order to standardize children’s palliative care education and training.MethodsOver four meetings the Action Group reviewed sources of evidence and guidance including palliative care competency documents and UK and Ireland quality and qualification frameworks. Expected levels of developing knowledge and skills were then agreed and identified competencies mapped to each level. The mapping process led to the development of learning outcomes, local indicative programme content and assessment exemplars.ResultsFour sections depicting developing levels of knowledge and skills were identified: Public Health, Universal, Core, Specialist. Each level has four learning outcomes: Communicating effectively, Working with others in and across various settings, Identifying and managing symptoms, Sustaining self-care and supporting the well-being of others. An audit tool template was developed to facilitate quality assurance of programme delivery. The framework and audit tool repository is on the International Children’s Palliative Care Network website for ease of international access.ConclusionsThe framework has received interest at UK, Ireland and International launches. While there are education programmes in children’s palliative care this is the first international attempt to coordinate education, to address lay carer education and to include public health.

Evaluation of Glottic Visualization and Ease of Intubation at Induction of General Anesthesia

Aim: To compare the frequency of better glottic visualization and ease of tracheal intubation in Macintosh versus McCoy blades. Study design: An observational analytical study. Settings: Department of Anesthesia, Lahore Medical and Dental College/Ghurki trust teaching hospital, Lahore. Study duration: Six months (2nd September 2017 to 1st March 2018) Methods: After approval from research, education and clinical audit department, we selected 60 patients for elective procedures under general anesthesia of age ranges from 20-40 years including both males and females. Patients were randomized by lottery method into two groups I & II. Laryngoscopy was performed with McCoy in group I and with Macintosh in group II and the best possible view of the glottis was obtained. After achieving best possible glottis view of each patient, vocal cord visualization was determined according to Grade-I to IV. Ease of tracheal intubation was also noted. Results: The demographic data was comparable in both groups. In this study, we have found better glottic visualization in 60.0% of patients with Macintosh blade (group II) and with McCoy blade (group I), it was 83.33% (p-value = 0.045). Ease of intubation was 73.33% with Macintosh blade (group II) and with McCoy blade (group I), it was 93.33% (p-value = 0.038). Conclusion: We concluded that frequency of better glottic visualization and ease of tracheal intubation with McCoy blade is higher as compared to Macintosh blade. Keywords: Endotracheal intubation, Glottic visualization, McCoy blades, Macintosh blades.

Evaluation of an Educational Outreach and Audit and Feedback Program to Reduce Continuous Pulse Oximetry Use in Hospitalized Infants With Stable Bronchiolitis

National guidelines recommend against continuous pulse oximetry use for hospitalized children with bronchiolitis who are not receiving supplemental oxygen, yet guideline-discordant use remains high. To evaluate deimplementation outcomes of educational outreach and audit and feedback strategies aiming to reduce guideline-discordant continuous pulse oximetry use in children hospitalized with bronchiolitis who are not receiving supplemental oxygen. A nonrandomized clinical single-group deimplementation trial was conducted in 14 non-intensive care units in 5 freestanding children's hospitals and 1 community hospital from December 1, 2019, through March 14, 2020, among 847 nurses and physicians caring for hospitalized children with bronchiolitis who were not receiving supplemental oxygen. Educational outreach focused on communicating details of the existing guidelines and evidence. Audit and feedback strategies included 2 formats: (1) weekly aggregate data feedback to multidisciplinary teams with review of unit-level and hospital-level use of continuous pulse oximetry, and (2) real-time 1:1 feedback to clinicians when guideline-discordant continuous pulse oximetry use was discovered during in-person data audits. Clinician ratings of acceptability, appropriateness, feasibility, and perceived safety were assessed using a questionnaire. Guideline-discordant continuous pulse oximetry use in hospitalized children was measured using direct observation of a convenience sample of patients with bronchiolitis who were not receiving supplemental oxygen. A total of 847 of 1193 eligible clinicians (695 women [82.1%]) responded to a Likert scale-based questionnaire (71% response rate). Most respondents rated the deimplementation strategies of education and audit and feedback as acceptable (education, 435 of 474 [92%]; audit and feedback, 615 of 664 [93%]), appropriate (education, 457 of 474 [96%]; audit and feedback, 622 of 664 [94%]), feasible (education, 424 of 474 [89%]; audit and feedback, 557 of 664 [84%]), and safe (803 of 847 [95%]). Sites collected 1051 audit observations (range, 47-403 per site) on 709 unique patient admissions (range, 31-251 per site) during a 3.5-month period of continuous pulse oximetry use in children with bronchiolitis not receiving supplemental oxygen, which were compared with 579 observations (range, 57-154 per site) from the same hospitals during the baseline 4-month period (prior season) to determine whether the strategies were associated with a reduction in use. Sites conducted 148 in-person educational outreach and aggregate data feedback sessions and provided real-time 1:1 feedback 171 of 236 times (72% of the time when guideline-discordant monitoring was identified). Adjusted for age, gestational age, time since weaning from supplemental oxygen, and other characteristics, guideline-discordant continuous pulse oximetry use decreased from 53% (95% CI, 49%-57%) to 23% (95% CI, 20%-25%) (P < .001) during the intervention period. There were no adverse events attributable to reduced monitoring. In this nonrandomized clinical trial, educational outreach and audit and feedback deimplementation strategies for guideline-discordant continuous pulse oximetry use among hospitalized children with bronchiolitis who were not receiving supplemental oxygen were positively associated with clinician perceptions of feasibility, acceptability, appropriateness, and safety. Evaluating the sustainability of deimplementation beyond the intervention period is an essential next step. ClinicalTrials.gov Identifier: NCT04178941.

Longitudinal associations with alcohol consumption during the first COVID-19 lockdown: Associations with mood, drinking motives, context of drinking, and mental health

BackgroundCoronavirus (COVID-19) resulted in lockdown measures in the UK, which has impacted alcohol use. Alcohol is often used as a coping mechanism and there are public health concerns regarding excessive consumption due to the pandemic. We aimed to longitudinally assess drinking behaviors, and associated factors, during the first UK government-mandated lockdown. MethodsAn online survey was distributed through social media (8th April 2020, onwards). Fortnightly follow up surveys were emailed to participants. The primary outcome measure was ‘weekly unit consumption’ and data was collected on a range of potentially related factors: demographics, factors relating to COVID-19 (e.g., health, work status), drinking motives, context of drinking, drinking intentions, mood, depression and anxiety. FindingsA total of 539 self-selected participants completed the baseline survey, with 186 completing at least 3 follow up surveys for multilevel modelling analysis. Personal coping motives, anxiety, drinking at home alone, and drinking at home with others were positively associated with alcohol consumption during lockdown. The following baseline measures also predicted increased consumption: male gender, lower education, and higher AUDIT scores (based on behavior prior to lockdown). Findings were consistent when utilizing an inverse probability weight to account for predictors of attrition (female, younger age, higher baseline AUDIT scores). ConclusionsThose already drinking at hazardous levels were more likely to increase their consumption, as were those who were drinking to cope. As we recover from the pandemic, there is a need for widespread alcohol support, and certain groups may need targeted support.

Results of a Stepped-Wedge Cluster-Randomized Implementation Science Trial to Improve Chlorhexidine Gluconate Bathing Compliance

Background: Daily chlorhexidine gluconate (CHG) bathing in intensive care units (ICUs) is widely supported in the literature to decrease risk of central-line-associated infections (CLABSIs). However, adoption of this practice is inconsistent. The primary objective of this implementation science study was to assess the effect of a bathing intervention on compliance with the AHRQ CHG bathing protocol. Secondary objectives were to examine (1) moderating effects of unit characteristics, (2) the intervention effect on nursing staff’s knowledge and perceptions of CHG bathing, and (3) the intervention effect on CLABSI rates. Methods: A stepped-wedge cluster-randomized design was used to implement and evaluate the effectiveness of a CHG bathing intervention. At 2 large hospitals, 14 units were clustered into 4 sequences. Units included 9 adult ICUs, 3 pediatric ICUs, 1 pediatric bone marrow transplant unit, and 1 adult hematology-oncology unit. Sequences were enrolled into the active intervention phase over the course of 4 months. The intervention included 2 evidence-based implementation strategies: (1) educational outreach visits and (2) audit and feedback on CHG bathing compliance. Compliance with the CHG bathing processes and daily CHG bathing documentation were assessed. At 12 months after the last enrolled date, booster sessions were completed, and outcomes were assessed for sustainability. Results: In models of CHG bathing process compliance, the implementation strategy was significant (b = 6.97; P = .009), indicating that compliance was 6.97% higher after the intervention than before. There was a statistically significant improvement in nursing knowledge of CHG bathing (χ2 = 9.32, p = .002) and perception of the priority of CHG bathing (t = 2.56; P = .01). Daily CHG bathing documentation compliance and CLABSI rates did not significantly improve immediately following the intervention; however, a clinically significant decrease (27.4%) in CLABSI rate was observed. At 12 months after the intervention, improvements in CHG bathing documentation and process outcomes were sustained. There was no change in bathing process compliance after 12 months (b = −0.19; P = .87; intercept=96.96, p &lt; .001), and compliance remained high at 96.96%. There was no change in documentation compliance after 12 months (b=3.89, p=.37, intercept=78.72, p &lt; .001), and compliance remained high at 78.72%. After 12 months, CLABSI rates were statistically significantly reduced (b = −0.16; P = .009; intercept =1.97, p &lt; .001). Conclusions: Using educational outreach visits and audit-and-feedback strategies can improve the adoption of evidence-based CHG bathing practices. CHG bathing—a simple, nurse-driven practice—can make a significant improvement in patient outcomes.Funding: NoDisclosures: None

Reduction of aggressive and violent behavior toward behavioral health unit staff and other patients: a best practice implementation project.

The current project aimed to implement evidence-based recommendations for the management of inpatient aggressive and violent behaviors in four behavioral health units (BHUs) in a mental healthcare area within an academic medical center. Patient violence against healthcare workers is a global concern, particularly in mental health care. All employees who work in inpatient psychiatric environments are at higher risk for targeted violence than are other healthcare workers. For healthcare organizations and staff, violent episodes involving patients can bring about medical expenses, potential legal expenditure, sick leave and a high turnover rate. The hospital at which this project was implemented had been experiencing a steady increase in violence and aggressive behavior. The project used the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice audit tool for promoting practice change in four BHUs. A baseline retrospective audit of 10 electronic health records from four BHUs assessed compliance with best practice regarding violent episodes. The Getting Research into Practice tool was used to identify barriers and develop an evidence-based educational strategy for 70 BHU staff aimed to improve compliance with best practice for managing aggression and violence. Staff education compliance was assessed via hospital education department records. A pre and postimplementation staff satisfaction survey assessed perceptions about education, confidence and unit safety. The baseline audit indicated that one of the three criteria had 0% compliance. Following implementation of an educational strategy using mock codes for BHU staff, there was 96% improvement in compliance for the BHU staff education audit criterion. Staff de-escalated patients in 83% of the episodes postimplementation. There was a slight decrease (9.1%) in the rate of violence across all four inpatient BHUs. Staff satisfaction survey findings did not show a statistically significant difference. Enhanced evidence-based education and mock codes resulted in BHU staff competence and confidence in managing aggressive and/or violent patients. Early signs of a decrease in the violence rate and improvement in the efficient use of de-escalation will be sustained with on-going yearly education, quarterly mock codes and future audits. This project was limited by its small size and short timeframe (21 weeks), making results not generalizable.

Results of the CHlorhexidine Gluconate Bathing implementation intervention to improve evidence-based nursing practices for prevention of central line associated bloodstream infections Study (CHanGing BathS): a stepped wedge cluster randomized trial

BackgroundCentral line-associated bloodstream infections (CLABSIs) result in approximately 28,000 deaths and approximately $2.3 billion in added costs to the U.S. healthcare system each year, and yet, many of these infections are preventable. At two large health systems in the southeast United States, CLABSIs continue to be an area of opportunity. Despite strong evidence for interventions to prevent CLABSI and reduce associated patient harm, such as use of chlorhexidine gluconate (CHG) bathing, the adoption of these interventions in practice is poor.The primary objective of this study was to assess the effect of a tailored, multifaceted implementation program on nursing staff’s compliance with the CHG bathing process and electronic health record (EHR) documentation in critically ill patients. The secondary objectives were to examine the (1) moderating effect of unit characteristics and cultural context, (2) intervention effect on nursing staff’s knowledge and perceptions of CHG bathing, and (3) intervention effect on CLABSI rates.MethodsA stepped wedged cluster-randomized design was used with units clustered into 4 sequences; each sequence consecutively began the intervention over the course of 4 months. The Grol and Wensing Model of Implementation helped guide selection of the implementation strategies, which included educational outreach visits and audit and feedback. Compliance with the appropriate CHG bathing process and daily CHG bathing documentation were assessed. Outcomes were assessed 12 months after the intervention to assess for sustainability.ResultsAmong the 14 clinical units participating, 8 were in a university hospital setting and 6 were in community hospital settings. CHG bathing process compliance and nursing staff’s knowledge and perceptions of CHG bathing significantly improved after the intervention (p = .009, p = .002, and p = .01, respectively). CHG bathing documentation compliance and CLABSI rates did not significantly improve; however, there was a clinically significant 27.4% decrease in CLABSI rates.ConclusionsUsing educational outreach visits and audit and feedback implementation strategies can improve adoption of evidence-based CHG bathing practices.Trial registrationClinicalTrials.gov, NCT03898115, Registered 28 March 2019.

Multi-faceted strategies improve collection compliance and sample acceptance rate for carbapenem-resistant Enterobacteriaceae (CRE) active surveillance testing

Active surveillance testing (AST) is one element of a comprehensive Carbapenem-resistant Enterobacteriaceae (CRE) prevention strategy. However, the utility of AST may be impacted by compliance with sample collection and the quality of specimens. Here, we describe strategies used to optimize a CRE AST program at a large academic medical center. Tests ordered, collected, rejected, and processed were tracked weekly for each participating unit. Sample collection compliance and acceptance rates were calculated and tracked weekly. Strategies were implemented to improve collection compliance and sample acceptance rates, including computerized provider order entry, printed educational materials, and audit and feedback. Weekly dedicated Infection Preventionist (IP) time was estimated. Over 35 months, mean collection compliance increased from 82.7% to 91.2%, and then decreased to 86.2%. Over 27 months, sample acceptance rate increased from 57.7% to 83.6%, and then remained stable at 83.4%. Over 39 months, dedicated weekly IP time decreased 92%. Use of evidence-based quality improvement strategies optimized our CRE AST program. Optimizing the AST process aids in early CRE detection, leading to timely isolation and preventing the spread of CRE to other patients. Other hospitals may benefit from these lessons and enhance local AST programs.

A Scoping Review of the Use of Social and Behavioral Change in Acute Care Antimicrobial Stewardship Initiatives.

Purpose: Antimicrobial stewardship (AS) initiatives are implemented with a goal of reducing antimicrobial resistance. It is unknown exactly how many acute care AS initiatives have since been based on social and behavioral theory. The purpose of this scoping review is to provide an updated review of theory-informed acute care AS initiatives in the published literature, including how social and behavioral theories have been used in the described interventions. Methods: PubMed, EMBASE, CINAHL, PsycINFO, and ProQuest Dissertations were searched using a combination of AS, acute care, and social and behavioral theory search terms from April 2011 to November 2019. Using both an initial review of titles and abstracts and a second review of full text, a total of 4 articles were identified after a review of 2014 records. Each article was coded using a guide that abstracted details of study methods, the AS intervention, and use of theory based on a validated theory coding scheme. Results: The interventions included combinations of decision-making tools, provider education, and prospective audit and feedback. Two studies included an evaluation of the described initiative, with findings indicating improvement in antimicrobial use. All interventions utilized theory in developing AS interventions. However, gaps were evident in the use of theory in the evaluations, including inconsistent measurement of theory constructs and lack of testing of the theory. Conclusion: AS interventions are frequently published; however, theory-based acute care AS interventions are not commonly described. More consistent and comprehensive utilization of social and behavioral theories may enhance effectiveness of AS programs.

Patient centred care in diagnostic radiography (Part 3): Perceptions of student radiographers and radiography academics

IntroductionAwareness is growing of the importance of patient centered care (PCC) in diagnostic radiography. PCC is embedded within professional body publications and guidance documents, but there is limited research evidence exploring the perceptions of student radiographers and radiography academics. MethodsThis paper reports Stage 1 and Stage 2 of the project from the perspective of radiography academic and student radiographer participants, and compares these to the perspectives of service users, clinical radiographers and radiography managers reported previously. Stage 1 used an online survey tool to gauge participant agreement with a series of attitudinal statements. Stage 2 used situational vignettes to promote discussion and debate about PCC approaches. ResultsResponse rates to the Stage 1 survey were above the minimum threshold, with 50 responses from student radiographers and 38 responses from radiography academics. Stage 1 participants were asked to participate in Stage 2 on a voluntary basis. As with service users and service deliverers, care communication, event interactions and control over environment were the key influences on PCC. However, students highlighted differences between reported and observed levels of PCC. ConclusionThere is some way to go to embed PCC in diagnostic radiography practice. As impartial observers of radiography practice, student radiographers highlight the difference between service users and service deliverer's perceptions of PCC. Whilst the focus of clinical radiographers remains on efficiency, it is difficult for student radiographers to challenge the accepted norm. Role models are required to promote PCC behaviours and a holistic approach in radiography practice. Implications for practiceA package of educational support and audit tools will be made available to support both service deliverers and student radiographers to deliver PCC.

78. Outcomes and adherence to institutional empiric therapy guidelines for the treatment of cystitis in ambulatory male veterans

BackgroundGuidelines provide primary literature demonstrating efficacy and safety of cystitis treatment in female patients, but not males. Increased antimicrobial resistance of urinary tract infection (UTI) pathogens to first line antibiotics are well-documented. In 2017, a change in institutional guidelines was made to recommend nitrofurantoin (NF) or cefpodoxime (CPD) as first line antibiotics for cystitis in males. This study aims to evaluate the efficacy of NF and CPD as first line treatment options in males with cystitis.MethodsSingle-center, retrospective chart review of male patients prescribed NF or CPD for treatment of cystitis in the outpatient setting from August 2017 to August 2018. Patients with asymptomatic bacteriuria, prostatitis or systemic signs and symptoms of UTI were excluded. Primary outcome was treatment failure, defined as requiring new emergency department (ED) or patient aligned care team (PACT) visit within 30 days after initiation of antibiotic for unresolved symptoms. Safety outcomes were based on documented adverse effects (AE) associated with antibiotic use. Chi-square was the primary statistical test for analyzing primary outcomes and other nominal variables.ResultsA total of 450 charts were reviewed with 150 patients meeting inclusion criteria (NF n = 75, CPD n = 75). Baseline characteristics were equally distributed between the two groups although the CPD group had higher serum creatinine compared to the NF group (p = 0.05). Nine patients (12%) in the NF group versus 13 patients (17.3%) in the CPD group returned to ED or PACT within 30 days (p=0.36). Inappropriate dosing was seen in 13 patients (17.3%) in the NF group vs. 2 patients (2.7%) in the CPD group (p = 0.005) and 44 patients (58.7%) in the NF group vs. 37 patients (49.3%) in the CPD group who received an inappropriate duration of treatment (p = 0.25). None of the patients reported AE associated with antibiotic use.ConclusionTreatment success rate of NF and CPD (88% and 82.7%, respectively) suggests that these agents might be effective first line antibiotics for cystitis in males. High rate of inappropriate long duration of treatment indicates the need for staff education and prospective audit and feedback for outpatient stewardship interventions.Disclosures All Authors: No reported disclosures

Інститут аудиту: сутність та його складові

The purpose of the article is to form the substantive essence of the concept of "audit institution" through the assessment of its compliance with the key parameters of socio-economic institutions and to develop a classification and hierarchy of its components. Research methods. General scientific techniques have been applied, including: the method of bibliographic research (to determine theoretical and methodological approaches to the disclosure and formation of the essence of the concept of “audit institution”); methods of analysis and assessment (to determine the compliance of the audit with the parameters of a socio-economic institution); modeling methods (to determine the internal structure of the audit institution, the classification and hierarchy of its components); generalization methods (to formalize the transformation of audit into an institution). Research results. The audit system was assessed for its compliance with the key parameters of the socio-economic institution. It was found that out of nine such parameters, the audit system meets five, and for four more audits as a socio-economic institution is formed. The internal components of the audit institution as a single ideological system are considered and highlighted. The classification and hierarchy of the constituent auditing institute have been developed. The expediency of using theoretical and methodological knowledge about the features, classification, hierarchy of construction in the development of programs and strategies for the development of audit has been substantiated. The structural model of the audit institution has been built and the mechanisms of its evolution have been disclosed. The definition of the category "socio-economic institution of audit" is given and its subject-functional essence is revealed. Scientific novelty. The theoretical concepts of the audit system were further developed by identifying its external correspondence with the characteristics of a socio-economic institution and the presence of an internal institutional structure with a classification and hierarchy of components characteristic of institutions. Thus, the foundations of the institutional paradigm and audit theory are formed. Practical significance. The practical significance lies in taking into account significant changes in the scientific and public perception of audit as an important socio-economic institution. Formed scientific support for the complex formation of the content of legislation, programs and strategies for the development of audit activities. The fundamental foundations of professional and public associations of auditors, the work of regulatory, educational and scientific audit institutions have been laid. Tabl.: 3. Figs.: 4. Refs.: 20.

How widely has ANTT been adopted in NHS hospitals and community care organisations in England and Scotland?

To the detriment of patient safety, the important clinical competency of aseptic technique has been notoriously variable in practice, and described ambiguously in the literature, internationally. From a UK perspective, attempts have been made to improve patient safety by reducing variability and improving education and practice through standardisation. The Welsh Government mandated Aseptic Non Touch Technique (ANTT®) as a specific national standard in 2015. All healthcare organisations in England are required by the Health and Social Care Act 2008 to have a single standard aseptic technique, demonstrable by the clinical governance indicators of education, training, competency assessment and compliance audit. In Scotland, an education-based initiative was launched by NHS Education for Scotland in 2012. To review the impact of these and other initiatives on the current status of aseptic technique, all NHS trusts in England and NHS health boards in Scotland were assessed under the Freedom of Information procedure. 93% of NHS trusts in England use a single standard for aseptic technique. In 88% of these trusts the single standard was stipulated as being ANTT. In Scotland, 62% of NHS acute and community care hospitals within health boards use a single standard. In 56% of these, the single standard was ANTT. When including those that use ANTT in combination with other techniques ANTT usage is 73%. These data demonstrate significant progress in standardising aseptic technique education, assessment and governance, and confirms ANTT as the de facto aseptic technique used in NHS trusts in England and health boards in Scotland.

Improving Timeliness of Internal Medicine Consults in the Emergency Department: A Quality Improvement Initiative.

Emergency department (ED) wait time is an important health system quality indicator. Prolonged consult to decision time (CTDT), the time it takes to reach a disposition decision after receiving a specialty consultation request, can contribute to increased overall length of stay in the ED. To identify delays in the consultation process for general internal medicine (GIM) and trial interventions to reduce CTDT. The study was conducted at a large tertiary teaching hospital with GIM inpatient wards at two campuses. Four interventions were trialed over sequential Plan-Do-Study-Act cycles: (1) process mapping, (2) resident education sessions, (3) audit and feedback of CTDT, and (4) adding a swing shift during peak consult volume. The primary outcome measures were mean CTDT for patients admitted to GIM and the proportion of admitted patients with CTDT of less than 3 hours. Mean CTDT decreased from 4.61 hours before intervention to 4.18 hours after intervention (p < .0001). The proportion of GIM patients with CTDT less than 3 hours increased from 25% to 33% (p < .0001). The interventions trialed led to a sustained reduction in CTDT over a 12-month period and demonstrated the effectiveness of education in influencing physician performance.