Implementation Of Core Elements Research Articles

Gaps in the implementation of national core elements for sustainable antimicrobial use in the WHO-African region

BackgroundAntimicrobial resistance (AMR) has emerged as a leading global health and economic threat of the 21st century, with Africa bearing the greatest burden of mortality from drug-resistant infections. Optimization of the use of antimicrobials is a core strategic element of the response to AMR, addressing misuse and overuse as primary drivers. Effectively, this requires the whole society comprising not only healthcare professionals but also the public, as well as the government, to engage in a bottom-up and a top-down approach. We determined the progress of African national governments in optimizing antimicrobial drug use.MethodsFrom September 2021 to June 2022, all 47 member states of the World Health Organization African region (WHO AFRO) were invited to participate in a survey determining the implementation of strategies to optimize antimicrobial use (AMU). We used the WHO antimicrobial stewardship (AMS) assessment tool, National core elements—A checklist to guide the country in identifying existing national core elements for the implementation of AMS Programs, to obtain information from national AMR focal persons. The tool consists of four sections—national plans and strategies; regulations and guidelines; awareness, training, and education; and supporting technologies and data—with a total of 33 checklist items, each graded from 0 to 4. The responses were aggregated and analyzed using Microsoft Excel 2020®.ResultsThirty-one (66%) of the 47 countries returned completed forms. Only eight (25.8%) countries have developed a national AMS implementation policy incorporating defined goals, targets, and operational plans. There are no budget lines for AMS activities in 23 (74.2%) countries. The WHO Access, Watch, Reserve (AWaRe) classification of optimizing AMU has been integrated into the national essential medicines list or formulary in 19 (61.3%) countries, while the incorporation of the AMS principles and WHO AWaRe classification into national clinical guidelines for the management of infections is present in only 12 (38.7%) and 11 (34.5%) countries, respectively. Although regulations on the prescription-only sale/dispensing of antibiotics are present in 68% of countries, their enforcement is poor. Systems identifying pathogens and antibiotic susceptibility for optimal use of antibiotics are lacking in 38% of countries.ConclusionIn Africa, wide gaps exist in the governments’ implementation of the core elements of optimizing antimicrobial drug use. Responding to AMR constitutes a long journey, and technical and financial support needs to be deployed to optimize the use of antimicrobials.

Progress in extreme heat management and warning systems: A systematic review of heat-health action plans (1995-2020)

In recent decades, rising trend in the number of heat waves (HWs) has exacerbated the risk of heat-related mortality and morbidity. The frequent deadly HWs precipitated a multitude of national and sub-national heat-health prevention and research efforts. In 2008, the WHO Regional Office for Europe developed and published guidance on heat-health action plans (HHAPs). This provided a blueprint for countries to design heat-related prevention efforts. Since then, a large corpus of new evidences and implementation experiences has emerged around adaptive measures, alert systems and urban planning interventions. The present study conducts a systematic review to critically assess the advent and development of HHAPs with a special focus on its integration with urban planning policies. It reviews the concept of threshold, indicators for heat event determination and measurement of HWs to understand trigger setting mechanisms. The results show that implementation of core elements of HHAPs varies significantly in the areas of long-term urban planning, real-time surveillance, monitoring and evaluation. Moreover, low levels of inclusion of HHAPs with national policies hinder the overall potential of adaptation measures. The growing impacts of HWs emphasize the urgent need to address spatial heat vulnerability and build urban heat resilience into implementable action plans.

Implementation of core elements of antibiotic stewardship in nursing homes-National Healthcare Safety Network, 2016-2018.

To assess the national uptake of the Centers for Disease Control and Prevention's (CDC) core elements of antibiotic stewardship in nursing homes from 2016 to 2018 and the effect of infection prevention and control (IPC) hours on the implementation of the core elements. Retrospective, repeated cross-sectional analysis. US nursing homes. We used the National Healthcare Safety Network (NHSN) Long-Term Care Facility Component annual surveys from 2016 to 2018 to assess nursing home characteristics and percent implementation of the core elements. We used log-binomial regression models to estimate the association between weekly IPC hours and the implementation of all 7 core elements while controlling for confounding by facility characteristics. We included 7,506 surveys from 2016 to 2018. In 2018, 71% of nursing homes reported implementation of all 7 core elements, a 28% increase from 2016. The greatest increases in implementation from 2016 to 2018 were in education (19%), reporting (18%), and drug expertise (15%). In 2018, 71% of nursing homes reported pharmacist involvement in improving antibiotic use, an increase of 27% since 2016. Nursing homes that reported at least 20 hours of IPC activity per week were 14% (95% confidence interval, 7%-20%) more likely to implement all 7 core elements when controlling for facility ownership and affiliation. Nursing homes reported substantial progress in antibiotic stewardship implementation from 2016 to 2018. Improvements in access to drug expertise, education, and reporting antibiotic use may reflect increased stewardship awareness and resource use among nursing home providers under new regulatory requirements. Nursing home stewardship programs may benefit from increased IPC staff hours.

Impact of Implementation of the Core Elements of Outpatient Antibiotic Stewardship Within Veterans Health Administration Emergency Departments and Primary Care Clinics on Antibiotic Prescribing and Patient Outcomes.

The Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use. We report the impact of core elements implementation within Veterans Health Administration sites. In this quasiexperimental controlled study, effects of an intervention targeting antibiotic prescription for uncomplicated acute respiratory tract infections (ARIs) were assessed. Outcomes included per-visit antibiotic prescribing, treatment appropriateness, ARI revisits, hospitalization, and ARI diagnostic changes over a 3-year pre-implementation period and 1-year post-implementation period. Logistic regression adjusted for covariates (odds ratio [OR], 95% confidence interval [CI]) and a difference-in-differences analysis compared outcomes between intervention and control sites. From 2014-2019, there were 16 712 and 51 275 patient visits within 10 intervention and 40 control sites, respectively. Antibiotic prescribing rates pre- and post-implementation within intervention sites were 59.7% and 41.5%, compared to 73.5% and 67.2% within control sites, respectively (difference-in-differences, P < .001). Intervention site pre- and post-implementation OR to receive appropriate therapy increased (OR, 1.67; 95% CI, 1.31-2.14), which remained unchanged within control sites (OR,1.04; 95% CI, .91-1.19). ARI-related return visits post-implementation (-1.3% vs -2.0%; difference-in-differences P = .76) were not different, but all-cause hospitalization was lower within intervention sites (-0.5% vs -0.2%; difference-in-differences P = .02). The OR to diagnose non-specific ARI compared with non-ARI diagnoses increased post-implementation forintervention (OR, 1.27; 95% CI, 1.21 -1.34) but not control (OR, 0.97; 95% CI, .94-1.01) sites. Implementation of the core elements was associated with reduced antibiotic prescribing for RIs and a reduction in hospitalizations. Diagnostic coding changes were observed.

Impact of Training Consultant Pharmacists on Antimicrobial Stewardship Programs in Long-Term Care Facilities

Background: The CDC recommends that consultant pharmacists support antimicrobial stewardship programs (ASPs) in long-term care facilities (LTCFs). We studied CDC-recommended ASP core elements implementation and antibiotic use in LTCFs before and after training consultant pharmacists. Methods: Between August 2017 and October 2017, consultant pharmacists from a regional long-term care pharmacy attended 5 didactic sessions preparing them to assist LTCFs in implementation of CDC-recommended ASP core elements. Training also included creating a process for evaluating appropriateness of all systemic antibiotics and providing prescriber feedback during their monthly mandatory drug-regimen reviews. Once monthly “meet-the-expert” sessions were held with consultant pharmacists throughout the project (November 2017 to December 2018). LTCF enrollment began in November 2017 and &gt;90% of facilities joined by January 2018. After enrollment, consultant pharmacists initiated ASP interventions including antibiotic reviews and feedback using standard templates. They also held regular meetings with infection preventionists to discuss Core Elements implementation and provided various ASP resources to LTCFs (eg, antibiotic policy template, guidance documents and standard assessment and communication tools). Data collection included ASP Core Elements, antibiotic starts, days of therapy (DOT), and resident days (RD). The McNemar test, the Wilcoxon signed-rank test, generalized estimating equation model, and the classic repeated measures approach were used to compare the presence of all 7 core elements and antibiotic use during the baseline (2017) and intervention (2018) year.Results: In total, 9 trained consultant pharmacists assisted 32 LTCFs with ASP implementation. When evaluating 27 LTCFs that provided complete data, a significant increase in presence of all 7 Core Elements after the intervention was noted compared to baseline (67% vs 0; median Core Elements, 7 vs 2; range, 6–7 vs 1–6; P &lt; .001). Median monthly antibiotic starts per 1,000 RD and DOT per 1,000 RD decreased in 2018 compared to 2017: 8.93 versus 9.91 (P &lt; .01) and 106.47 versus 141.59 (P &lt; .001), respectively. However, variations in antibiotic use were detected among facilities (Table 1). When comparing trends, antibiotic starts and DOT were already trending downward during 2017 (Fig. 1A and 1B). On average, antibiotic starts decreased by 0.27 per 1,000 RD (P &lt; .001) and DOT by 1.92 per 1,000 RD (P &lt; .001) each month during 2017. Although antibiotic starts remained mostly stable in 2018, DOT continued to decline further (average monthly decline, 2.60 per 1,000 RD; P &lt; .001). When analyzing aggregated mean, antibiotic use across all sites per month by year, DOT were consistently lower throughout 2018 and antibiotic starts were lower for the first 9 months (Fig. 1C and 1D). Conclusions: Consultant pharmacists can play an important role in strengthening ASPs and in decreasing antibiotic use in LTCFs. Educational programs should be developed nationally to train long-term care consultant pharmacists in ASP implementation.Funding: Merck &amp; Co., Inc, provided funding for this study.Disclosures: Muhammad Salman Ashraf and Scott Bergman report receipt of a research grant from Merck.

Update on Improving Outpatient Antibiotic Use Through Implementation and Evaluation of Core Elements of Outpatient Antibiotic

Background: Acute respiratory infections (ARIs) are a key target to improve antibiotic use in the outpatient setting. The Core Elements of Outpatient Antibiotic Stewardship provide a framework for improving antibiotic use, but data on safety and effectiveness of interventions to improve antibiotic use are limited. We report the impact of Core Elements implementation within Veterans’ Healthcare Administration clinics on antibiotic prescribing and patient outcomes. Methods: The intervention targeting treatment of uncomplicated ARIs (sinusitis, pharyngitis, bronchitis, and viral upper respiratory infections [URIs]) in emergency department and primary care settings was initiated within 10 sites between September 2017 and January 2018. The intervention was developed using the Core Elements and included local site champions, audit-and-feedback with peer comparison, and academic detailing. We evaluated the following outcomes: per-visit antibiotic prescribing rates overall and by diagnosis; appropriateness of treatment; 30-day ARI revisits; 30-day infectious complications (eg,, pneumonia,); 30-day adverse medication effects; 90-day Clostridium difficile infection (CDI); and 30-day hospitalizations. Multilevel logistic regression was used to calculate rate ratios (RR) with 95% CI for each outcome in the postintervention period (12 months) compared to the preintervention period (39–42 months). Results: There were 14,020 uncomplicated ARI visits before the intervention and 4,866 uncomplicated ARI visits after the intervention. The proportions of uncomplicated ARI visits with antibiotics prescribed were 59.17% before the intervention versus 44.34% after the intervention. A trend in reduced antibiotic prescribing for ARIs throughout the entire (before and after) observation period was evident (0.92; 95% CI, 0.90–0.94); however, a significant reduction in antibiotic prescribing after the intervention was identified (0.74; 95% CI, 0.59–0.93). Per-visit antibiotic prescribing rates decreased significantly for bronchitis and URI (0.54; 95% CI, 0.44–0.65), pharyngitis (0.76; 95% CI, 0.67–0.86), and sinusitis (0.92; 95% CI, 0.85–1.0). Appropriate therapy for pharyngitis increased (1.43; 95% CI, 1.21–1.68), but appropriate therapy for sinusitis remained unchanged (0.92; 95% CI, 0.85–1.0) after the intervention. Complications associated with antibiotic undertreatment were not different after the intervention: ARI-related revisit rates (1.01; 95% CI, 0.98–1.05) and infectious complications (1.01; 95% CI, 0.79–1.28). A potential benefit of improved antibiotic use included a reduction in visits for adverse medication effects (0.82; 95% CI, 0.72–0.94). Furthermore, 90-day CDI events were too sparse to model: preintervention incidence was 0.08% and postintervention incidence was 0.06%. Additionally, 30-day hospitalizations were significantly lower in the postintervention period (0.79; 95% CI, 0.72–0.87). Conclusions: Implementation of the Core Elements was safe and effective and was associated with reduced antibiotic prescribing rates for uncomplicated ARIs, improvements in diagnosis-specific appropriate therapy, visits for adverse antibiotic effects, and 30-day hospitalization rates. No adverse events were noted in ARI-related revisit rates or infectious complications. CDI rates were low and unchanged.Funding: NoneDisclosures: None

Implementeren en Leren

Abstract To implement, and learn. The implementation and subsequent lessons of a module aimed at enhancing home-based parental literacy involvement With this study, we (a) analyze the implementation of the parental involvement module of Success for All aimed at enhancing home-based parental literacy involvement in the first, second, and third Grade, and (b) draw lessons from that implementation. For three school years, seven Dutch elementary schools with relatively many students from low socio-economic backgrounds, have implemented the parental involvement module. Afterwards, in-depth interviews with 22 professionals have been conducted. Based on the interview data, two dimensions of implementation have been analyzed: the level of structural implementation and the process of implementation. We distinguished three levels of structural implementation: low, medium, and high. Our analyses reveal that one school obtained a medium level of structural implementation, and the other six a low level. With knowledge of the process of implementation, we interpreted this outcome. Our analyses show that a higher level of structural implementation relies on (1) how the innovation is embedded in the school’s organizational structure, (2) whether or not a program champion (who is supported by coworkers and supervisors) is present, (3) the necessity felt for successful implementation of core elements of the module, (4) the enthusiasm of the school’s staff for the innovation, (5) asking the help of external experts in order to, with joint forces, help solve a blockage in the implementation process and (6) active involvement of parents and positive parental responses.

1031. Effect of On-Site ID Specialist Led, Antimicrobial Stewardship Pharmacist Driven Program on Provider Acceptance, Antimicrobial Utilization and Clostridoides Infection Rates In a Community Hospital / Rural Regional Referral Center

BackgroundAntibiotic Stewardship (ASP) standards for hospitals became effective January 1, 2017. Core Elements implementation guidelines have been challenging for rural hospitals usually lacking on-site expertise. Our 170-bed Community Hospital / rural referral center has dedicated resources for on-site ASP. Our team includes on-site Infectious Disease (ID) Specialist and dedicated ASP pharmacist. Over first 2 years, our model shows very high provider acceptance, improvement in antimicrobial use pattern and reduction in the number of Clostridioides difficile infections (CDI).MethodsThe ASP Pharmacist conducted a daily review of ASP targets. He met with on-site ID Physician 3 days weekly to discuss interventions and review complex cases. The ASP team - ID Medical Director, ASP Pharmacist, Microbiologist, Invention Preventionist and Hospitalist met monthly to discuss outcomes and facility-wide interventions.ASP audit included: positive cultures, patients on multiple or broad-spectrum antimicrobials, patients receiving dual nephrotoxic drugs, carbapenems, fluoroquinolones, candidates for IV to PO conversionThe audit results were communicated in-person to attending physician and documented in electronic medical record.ResultsASP team recommendations were accepted in 94% of casesID consult was recommended in 4.69% and was accepted 100%. Top 20 IV antimicrobial use decreased by 10%. Fluoroquinolones (29%) and carbapenems (28%) showed highest decrease. Cephalosporins showed small increase. Hospital-acquired CDI rate decreased from 0.83 cases/ 1000 patient-days (PD) pre-ASP to 0.53 cases/ 1000 PD post-ASP. General CDI diagnosis decreased from 3.21 cases/1000 PD pre-ASAP to 2.23 cases/ 1000 PD post-ASPConclusionAn on-site, ID Specialist reviewed and dedicated ASP Pharmacist driven program at a rural referral center/ Community Hospital significantly improved antibiotic use and decreased Clostridium Difficile Infections in the first 2 years. Direct feedback of ASP review to providers resulted in an excellent acceptance rate. On-site ID and ASP Pharmacist collaboration is logistically difficult to achieve but expanding our model to rural referral centers should be considered. More research is needed to determine the cost-effectiveness of onsite, dual led programs. Disclosures All authors: No reported disclosures.

Frequently Identified Gaps in Antimicrobial Stewardship Programs in Critical Access Hospitals

BackgroundNebraska (NE) Infection Control Assessment and Promotion Program (ICAP) is a CDC funded project. ICAP team works in collaboration with NE Department of Health and Human Services (NEDHHS) to assess and improve infection prevention and control programs (IPCP) in various health care settings including resource limited settings like critical access hospitals (CAH). Little is known about the existing gaps in antimicrobial stewardship programs (ASP) of CAH. Hence, we decided to study the current level of ASP activities and factors associated with these activities in CAH.MethodsNE ICAP conducted on-site surveys in 36 CAH from October 2015 to February 2017. ASP activities related to the 7 CDC recommended core elements (CE) including leadership support (LS), accountability, drug expertise (DE), action, tracking, reporting, and education were assessed using a CDC Infection Control Assessment Tool for acute care hospitals. Descriptive analyses evaluated CAH characteristics and frequency of CE implementation. Fisher’s exact, Mann–Whitney, and Kruskal–Wallis tests were used for statistical analyses examining the association of various factors with level of ASP activities.ResultsThe 36 surveyed CAH had a median of 20 (range 10–25) beds and employed a median of 0.4 (range 0.1–1.6) infection preventionist (IP) full-time equivalent (FTE)/25-bed. Frequency of CE implementation varied among CAH with action and LS as the most (69%) and least (28%) frequently implemented elements, respectively. Close to half (47%) of surveyed CAH had implemented ≥4 CE but only 14% of facilities had all 7 CE. Median bed size and IP FTE/25-bed were similar among CAH with 0–2, 3-5, or ≥6 CE in place. CAH with LS or accountability for ASP implemented higher median numbers of the remaining CE compared with CAH without LS or accountability (5 vs. 2, P < 0.01 and 4 vs. 2, P < 0.01, respectively). Facilities with The presence of LS, accountability and drug expertise were more likely to have all 4 remaining CE implemented than others (56% vs. 8%, P < 0.01).ConclusionLS, accountability, and DE are important factors for the implementation of the remaining 4 CE in CAH. Although LS was the least frequently implemented CE, when present was associated with implementation of most of the other CE. Acquiring LS will facilitate implementation of additional ASP efforts in CAH.Disclosures All authors: No reported disclosures.

The chronic care for age-related macular degeneration study (CHARMED): Study protocol for a randomized controlled trial

BackgroundNeovascular age-related macular degeneration is the leading cause of irreversible blindness in people 50 years of age or older in the developed world. As in other chronic diseases, several effective treatments are available, but in clinical daily practice there is an evidence performance gap. The Chronic Care Model represents an evidence-based framework for the care of chronically ill patients and aims at closing that gap. However, no data are available regarding patients with neovascular age-related macular degeneration.Methods/DesignCHARMED is a multicenter randomized controlled trial. The study challenges the hypothesis that the implementation of core elements of the Chronic Care Model (patient empowerment, delivering evidence based information, clinical information system, reminder system with structured follow up and frequent monitoring) via a specially trained Chronic Care Coach in Swiss centres for neovascular age-related macular degeneration results in better visual acuity (primary outcome) and an increased disease specific quality of life (secondary outcome) in patients with neovascular age-related macular degeneration. According to the power calculation, a total sample size of 352 patients is needed (drop out rate of 25%). 14 specialised medical doctors from leading ophtalmologic centres in Switzerland will include 25 patients. In each centre, a Chronic Care Coach will provide disease specific care according to the Chronic Care Model for intervention group. Patients from the control group will be treated as usual. Baseline measurements will be taken in month III - XII, starting in March 2011. Follow-up data will be collected after 6 months and 1 year.DiscussionMultiple studies have shown that implementing Chronic Care Model elements improve clinical outcomes as well as process parameters in different chronic diseases as osteoarthritis, depression or e.g. the cardiovascular risk profile of diabetes patients. This study will be the first to assess this approach in neovascular age-related macular degeneration. If our hypothesis will be confirmed, the implementation of this approach in routine care for patients with with neovascular age-related macular degeneration should be considered.Trial RegistrationCurrent controlled trials ISRCTN32507927.