Local Champions Research Articles

A pilot intervention trial to reduce the use of post-procedural antimicrobials after common endourologic surgeries.

Post-procedural antimicrobial prophylaxis is not recommended by professional guidelines but is commonly prescribed. We sought to reduce use of post-procedural antimicrobials after common endoscopic urologic procedures. A before-after, quasi-experimental trial with a baseline (July 2020-June 2022), an implementation (July 2022), and an intervention period (August 2022-July 2023). Three participating medical centers. We assessed the effect of a bundled intervention on excess post-procedural antimicrobial use (ie, antimicrobial use on post-procedural day 1) after three types of endoscopic urologic procedures: ureteroscopy and transurethral resection of bladder tumor or prostate. The intervention consisted of education, local champion(s), and audit-and-feedback of data on the frequency of post-procedural antimicrobial-prescribing. 1,272 procedures were performed across all 3 sites at baseline compared to 525 during the intervention period; 644 (50.6%) patients received excess post-procedural antimicrobials during the baseline period compared to 216 (41.1%) during the intervention period. There was no change in the use of post-procedural antimicrobials at sites 1 and 2 between the baseline and intervention periods. At site 3, the odds of prescribing a post-procedural antimicrobial significantly decreased during the intervention period relative to the baseline time trend (0.09; 95% CI 0.02-0.45). There was no significant increase in post-procedural unplanned visits at any of the sites. Implementation of a bundled intervention was associated with reduced post-procedural antimicrobial use at one of three sites, with no increase in complications. These findings demonstrate both the safety and challenge of guideline implementation for optimal perioperative antimicrobial prophylaxis.This trial was registered on clinicaltrials.gov, NCT04196777.

Co-designing health literacy actions: Connecting the dots to create meaningful impact

Abstract In closing the workshop, this presentation will bring together the participatory research recommendations for promoting and developing healthy literacy in Ireland, which will be led by Slaintécare Healthy Communities in practice, dissemination and scale up. In particular, a worked example from a third Slaintécare Healthy Community (Westmeath) will be presented; a healthy literacy “Train the Trainer” professional development course for local health literacy champions. In this presentation, we will also challenge attendees to offer suggestions of how to support and facilitate other recommendations suggested by our participants, and invite them to consider how this participatory action approach to a health literacy needs analysis could be utilised in their own contexts.

Analysis of implementation science strategies to train laparoscopic surgical skills among Liberian surgeons using ALL-SAFE.

Significant disparities exist in laparoscopic training opportunities for surgeons in low- and middle-income countries (LMICs). ALL-SAFE is an innovative, low-cost training system for LMIC surgeons' laparoscopic development. However, strategies to implement and scale ALL-SAFE are unstudied. We aimed to assess the impact of implementation science strategies on ALL-SAFE uptake in Liberia, a novel and low-resource context. This study used implementation science approaches to evaluate ALL-SAFE uptake in three Liberian hospitals: John F. Kennedy Medical Center, Phebe, and ELWA. Five validated implementation strategies of program orientation, local champions, network weaving, feedback mechanisms, and practical supervision were piloted. All five strategies were implemented at two hospitals, while four strategies, excluding clinician supervision, were implemented at the final site as a pseudo-control, to evaluate the impact of resource-intensive supervision. Participants included surgical consultants, residents, and medical students. Engagement was assessed with mixed methods including participant number, practice hours, module completion rates, and strategy feasibility through end-user interviews. Across three hospitals, 33 participants used ALL-SAFE for 87.8 total training hours (5,268min). Participant numbers varied across sites (NJFK = 20, 80%; NPhebe = 7, 88%; NELWA = 6, 86%), as did practice times (TotalJFK = 3,060min, Median time/ParticipantJFK = 103min; TotalPhebe = 1,434min, Median time/ParticipantPhebe = 126min; TotalELWA = 774min, Median time/ParticipantELWA = 100min). Sites with practical supervision demonstrated higher engagement than those without (P = 0.042). Interviews (n = 8) revealed positive perceptions toward program orientation, practical supervision, and network weaving. Participants recommended thirteen additional strategies for sustainability including translating ALL-SAFE skills to patient care. Our study is one of the first to evaluate implementation science strategies for laparoscopic training in sub-Saharan Africa. The implementation bundles of five validated strategies were considered feasible by Liberian surgeons in both urban and rural hospitals. Mixed methods suggested a positive association between engagement and the resource-intensive practical supervision strategy. Future studies should focus on quantifying individual strategy contributions with rigorous implementation designs and assessing sustainability strategies.

Strategies for implementation of a transmural fall-prevention care pathway for older adults with fall-related injuries at the emergency department

BackgroundAlthough indicated, referrals for multifactorial fall risk assessments in older adults with fall related injuries presenting at the emergency department (ED) are not standard. The implementation of a transmural fall-prevention care pathway (TFCP) could bridge this gap by guiding patients to multifactorial fall risk assessments and personalised multidomain interventions in primary care. This study aims to develop and evaluate implementation strategies for a TFCP.MethodsIn this mixed-methods implementation study, strategies were developed using the Consolidated Framework for Implementation Research Expert Recommendations for Implementing Change Matching Tool. These were evaluated with patients, involved healthcare professionals, and other stakeholders using the Reach, Adoption, Implementation, and Maintenance of the RE-AIM framework in two cycles. Patients of the TFCP consisted of frail community dwelling individuals aged 65 and over presenting at the ED with fall related injuries.ResultsDuring the first implementation phase, strategies were focussed on assessing readiness, adaptability, local champions, incentives and education for all involved healthcare professions in the TFCP. Only 34.4% of eligible patients were informed of the TFCP at the ED, 30.6% agreed to a fall risk assessment and 8.3% patients received the fall risk assessment. In the second phase, this improved to 67.1%, 64.6%, and 35.4%, respectively. Strategies in this phase focussed on adaptability, obtaining sustainable financial resources, local champions, assessing readiness, and education. The implementation was facilitated by strategies related to awareness, champion recruitment, educational meetings, adaptability of TFCP elements and evaluations of facilitators and barriers.ConclusionThe study outlined strategies for implementing TFCPs in EDs. Strategies included increasing awareness, utilising local champions, educational initiatives, adaptability of the TFCP, and continuous monitoring of facilitators and barriers. These insights can serve as a blueprint for enhancing fall prevention efforts for older adults in emergency department settings.

Investigating the impact of a multicomponent positive participatory organisational intervention on burnout in New Zealand emergency department staff: a prospective, multisite, before and after, mixed methods study.

The well-being of healthcare workers (HCWs) is critical to providing excellent care. Recent evidence concerns the well-being of emergency department (ED) HCWs in New Zealand, with high levels of burnout found in a 2020 survey. This threat to providing high-quality acute care warrants improvement interventions. The causes of burnout are complex and multifactorial, the solutions are not straightforward. A prospective, multisite, before and after, mixed methods study assessing a multicomponent intervention, adaptable to local context, that targets three organisation levels (the individual, the group and the system levels) and meaningfully involves frontline HCWs may reduce HCW burnout and improve HCW well-being. Individual HCWs will choose from three individual-level psychological interventions and participate in those most appropriate for them. Local champions will decide which group-level intervention their ED will use. The system-level intervention will build capacity and capability for quality improvement (QI) with QI training and the establishment of a Quality Improvement Learning System. This system-level intervention has several important features that may ultimately empower HCWs to contribute to improving the quality of ED healthcare.We will enrol nine EDs, from which there will be at least 900 HCW participants. EDs will be enrolled in three waves from March 2023 to April 2024, with interventions taking place in each ED over 12 months.Methods of assessment will include baseline and repeat survey measures of burnout and well-being. Process evaluation at each ED will provide details of context, the intervention and the fidelity of the implementation. Ethics committee approval was provided, with locality approval at each site.Individual site feedback will be provided to each ED and executive leadership. Dissemination of findings will be through publication in peer-reviewed journals, presentation at national and international scientific meetings and through national healthcare quality bodies. Australia New Zealand Clinical Trials Registry (ACTRN12623000342617).

Local and national stakeholders collaborate to take on Prosopis invasions with biological control and biomass use in South Africa

Research that directs the way stakeholders act and how they collaborate is essential when addressing complex environmental challenges in the field of sustainability science. For example, researchers attempting to manage Prosopis invasions through biological control in South Africa have historically faced challenges from stakeholders. In this study, we illustrate the importance of stakeholder engagement and social learning by outlining the collaborative efforts of various stakeholders to promote effective, integrative and sustainable management of Prosopis invasions in the Northern Cape, South Africa. Through a community of practice approach, stakeholders worked together over the past half-decade in an attempt to develop a National Strategy for Prosopis management and improve its control. This strategy aimed not only to emphasise the need for integration of biomass use (aimed at offsetting the costs of mechanical clearing and necessary herbicide use) but also to underscore the significance of biocontrol alongside other management approaches. Stakeholders also identified that adequate farm-scale planning is necessary to provide a sense of purpose and assist in monitoring of progress. We worked alongside land managers and experts to develop such plans. The engagement of local champions played a crucial role in facilitating collaboration and learning among stakeholders, emphasising the significance of inclusive approaches in addressing complex sustainability challenges. In addition, we gained an understanding of how to develop the community of practice to enhance collaboration that ensures the implementation of plans to better manage Prosopis. Our findings underscore the necessity of meaningful stakeholder engagement and collaboration in effective invasive species management. By promoting understanding and involvement of diverse stakeholders, initiatives can have a greater impact in addressing broader sustainability issues.

Early-stage implementation of peer-led interventions for emergency department patients with substance use disorder: Findings from a formative qualitative evaluation

IntroductionEmergency department (ED)-based peer recovery coach (PRC) programs can improve access to substance use disorder treatment (SUD) for ED patients. As literature on early stages of PRC implementation is limited, we conducted a qualitative assessment of ED PRC program implementation from several US-based PRC programs focusing on barriers and facilitators for implementation and providing recommendations based on the findings. MethodsWe collected qualitative data from 39 key informants (peer recovery coaches, PRC program managers, ED physicians and staff, representatives of community-based organizations) via 6 focus groups and 21 interviews in February–December 2023. We transcribed audio-recordings and analyzed data using codebook thematic analysis. ResultsWe identified the following major themes related to specific barriers and recommendations to address them. To facilitate timely linkage to PRCs, programs would regularly inform ED staff about the program and its linkage procedures, establish trust between PRC and ED staff, streamline the linkage procedures, and choose an “opt-out” linkage approach. To address barriers related to external referrals, programs use “warm handoff” and “warm line” strategies, maintain and update a comprehensive catalog of resources, and familiarize peer coaches with local service providers. Telehealth services implementation requires addressing logistical barriers, ensuring patients' privacy, and training peer coaches on building trust and rapport online. Peer coaches' wellness and quality of services can be improved by limiting PRC's workload, prioritizing quality over quantity, facilitating self-, peer- and professional care to mitigate stress and burnout; and, importantly, by providing supportive supervision and training to peer coaches and advocating for PRC team as an equal partner in the ED settings. To facilitate PRC program adoption and sustainment program managers engage local communities and program champions, seek diverse sources of funding, and advocate for structural changes to accommodate recruitment and retention of peer recovery coaches. ConclusionsWe compiled a wealth of best practices used by PRC programs to address numerous implementation barriers and challenges. These recommendations are intended for PRC program planners, managers and champions, hospital leadership, and state and local public health agencies leading SUD epidemic response.

Cardiac positron emission tomography and other modalities for coronary artery disease assessment: A snapshot from the medicare data

BackgroundPositron emission tomography (PET) is an important tool for assessing coronary artery disease (CAD), but its widespread utilization is limited due to various factors, including limited local champion availability. This study aims to compare the frequency of PET procedures and their interpreters with other common CAD assessment modalities. MethodsUsing Medicare data, we examined the number of cardiac PET procedures billed and compared them with single-photon emission computed tomography (SPECT), coronary computed tomography angiography (CCTA), stress magnetic resonance imaging (MRI), and stress echocardiography. Healthcare Common Procedure Coding System codes were used to identify procedures. We calculated the total number of PET myocardial perfusion imaging (MPI) procedures, the proportion of PET/CT and myocardial blood flow (MBF) assessments, and the median number of studies read per physician. We also analyzed the trends in the use of different CAD assessment modalities between 2018 and 2022. Descriptive statistics summarized the data. ResultsIn 2022, Medicare billed for 212,106 PET MPI scans. SPECT was six times more frequent (1,343,519), whereas stress echocardiography (201,676) and CCTA (118,734) had similar or lower use. Stress MRI (3,932) was least used. Of the PET MPI scans, 46% were PET/CT, and 39% included MBF measurements. Cardiologists interpreted 86% of PET scans, with a median of 58 studies per reader; 23% interpreted ≤25 studies annually. SPECT had a median of 63 studies per reader, and CCTA, stress MRI, and stress echocardiography had medians of 27, 20, and 24, respectively. PET, CT, and MRI use increased from 2018 to 2022, whereas SPECT and stress echocardiography declined. ConclusionIn the Medicare population, radionuclide perfusion imaging (SPECT and PET) remained the preferred method for assessment of CAD, with SPECT being the most frequently used modality and PET being the second most frequently used modality for this application. However, PET/CT and MBF are underutilized, limiting diagnostic and prognostic capabilities. Efforts to enhance education and awareness of PET's advantages and to address barriers to its wider adoption are essential to maximize its clinical benefits and improve patient outcomes.

Role of Community Participation in Achieving Low Carbon Lifestyles in Kuala Lumpur

This paper examines community engagement in Kuala Lumpur's Low Carbon Lifestyle (LCL) programs, led by Local Agenda 21 Kuala Lumpur (LA21KL). It investigates how community participation can drive the city's goal to achieve zero carbon emissions by 2050. The study identifies three key themes based on qualitative research and in-depth interviews: empowering community participation, strengthening engagement in low programs, and green urban governance. This study emphasises the importance of raising awareness about the benefits of LCL programs to boost community involvement. Strategies like fostering local champions are essential for successfully implementing these initiatives.

Initiatives and exposures associated with food security in remote and isolated communities: a scoping review.

Chronic household food insecurity (HFI) and lack of food availability and accessibility in isolated communities are longstanding public health crises. This review aims to paint a more fulsome picture of food security initiatives in remote and isolated communities by examining programs across circumpolar countries, Australia, and Aotearoa New Zealand. This synthesis of research will contribute to an understanding of what types of initiatives exist and aid in the identification of best practices. The authors conducted a scoping review identifying articles that include either (1) an evaluation of an initiative with a quantitative food security outcome in remote and isolated communities, or (2) quantitative associations between exposure factors with food security outcomes. Inclusion criteria included English and French articles focused on remote and isolated communities in Canada, the US, Australia, New Zealand, Sweden, Norway, Finland, Greenland, and Russia from January 1997 to July 2022. The article search yielded 1882 results, of which 96 fulfilled the inclusion criteria, including 26 studies evaluating initiatives, 66 studies evaluating exposure factors, and four studies that included both initiatives and exposure factors. The majority of the studies included in this review were conducted in Canada and Australia. No initiative studies conducted in Russia, Greenland, Norway, Finland, or Sweden fulfilled the criteria for inclusion in this review. The most common types of initiatives evaluated included school-based programs, market subsidies, and education initiatives, though a small number (<5) of other programs were evaluated, including traditional food programs and greenhouses. Though multiple programs resulted in lower food costs or increases in healthy food consumption in remote regions, the cost of a healthy diet in these areas remained high, as do levels of HFI. Factors associated with improved food security outcomes included higher income level, access to adequate housing, higher education level, access to transportation for harvesting, and the level of remoteness of a community. The studies included in this review also stressed the importance of access to and affordability of harvesting traditional foods in these regions. Those living in remote and isolated communities are particularly vulnerable to food insecurity and lack of access and availability of healthy foods, which are compounded by a variety of socioeconomic factors. This study highlights the lack of quantitative evaluations of food security initiatives in remote and isolated communities, as well as the wide variety in measured outcomes. Authors of several of the included articles note that community-led initiatives, with strong partnerships and local champions, were recommended in these populations, given the culturally and geographically diverse groups living in remote and isolated areas.

Bringing a Systems Approach to Living Donor Kidney Transplantation

BackgroundLiving donor kidney transplantation (LDKT) is the best treatment option for patients with kidney failure. Efforts to increase LDKT have focused on micro-level interventions and the need for systems thinking has been highlighted. We aimed to identify and compare health system-level attributes and processes that are facilitators and barriers to LDKT. MethodsWe conducted a qualitative comparative case study analysis of three Canadian provincial healthcare systems with variable LDKT performance (Quebec:low, Ontario:moderate-high, British Columbia:high). Data collection entailed semi-structured interviews (n=91), document review (n=97) and focus groups (n=5 with 40 participants), analyzed using inductive thematic analysis. ResultsOur findings showed a strong relationship between the degree of centralized coordination between governing organizations and the capacity to deliver LDKT: 1) Macro-level coordination between governing organizations in British Columbia and Ontario increased capacities, while Québec was seen as decentralized with little formal coordination; 2) A higher degree of centralized coordination facilitated more effective resource deployment in the form of human resources and initiatives in British Columbia and Ontario, whereas in Québec resource deployment relied on hospital budgets leading to competition for resources and reduced capacity of initiatives; 3) Informal resource sharing through strong communities of practice and local champions facilitated LDKT in Ontario and British Columbia and was limited in Québec. ConclusionOur findings suggest that interventions that account for full-system function, particularly macro-level coordination between governing organizations can improve LDKT delivery. Findings may be used to guide structured organizational change towards increasing LDKT and mitigating the global burden of kidney failure.

Community Participation in Low Carbon Lifestyle Programs in Kuala Lumpur -

This paper explores community engagement in Kuala Lumpur's Low Carbon Lifestyle (LCL) programs, led by Local Agenda 21 Kuala Lumpur (LA21KL). It focuses on how community participation can advance the city's goal of achieving zero carbon emissions by 2050. Through qualitative research and in-depth interviews, the study highlights three themes: Empowering Community Participation, Strengthening Engagement in Low Carbon Programs, and Green Urban Governance. It emphasises the need for increased awareness of the benefits of LCL programs to strengthen community involvement. Strategies like developing local champions are essential for successfully implementing these initiatives.

Factors influencing the development, recruitment, integration, retention and career development of advanced practice providers in hospital health care teams: a scoping review

BackgroundAdvanced practice providers (APPs), including physician assistants/associates (PAs), nurse practitioners (NPs) and other non-physician roles, have been developed largely to meet changing healthcare demand and increasing workforce shortages. First introduced in primary care in the US, APPs are prevalent in secondary care across different specialty areas in different countries around the world. In this scoping review, we aimed to summarise the factors influencing the development, recruitment, integration, retention and career development of APP roles in hospital health care teams.MethodsWe conducted a scoping review and searched Ovid MEDLINE, Ovid Embase, Ovid Global Health, Ovid PsycINFO and EBSCOhost CINAHL to obtain relevant articles published between Jan 2000 and Apr 2023 that focused on workforce management of APP roles in secondary care. Articles were screened by two reviewers independently. Data from included articles were charted and coded iteratively to summarise factors influencing APP development, recruitment, integration, retention and career development across different health system structural levels (macro-, meso- and micro-level).ResultsWe identified and analysed 273 articles that originated mostly from high-income countries, e.g. the US (n = 115) and the UK (n = 52), and primarily focused on NP (n = 183) and PA (n = 41). At the macro-level, broader workforce supply, national/regional workforce policies such as work-hour restrictions on physicians, APP scope of practice regulations, and views of external collaborators, stakeholders and public representation of APPs influenced organisations’ decisions on developing and managing APP roles. At the meso-level, organisational and departmental characteristics, organisational planning, strategy and policy, availability of resources, local experiences and evidence as well as views and perceptions of local organisational leaders, champions and other departments influenced all stages of APP role management. Lastly at the micro-level, individual APPs’ backgrounds and characteristics, clinical team members’ perceptions, understanding and relationship with APP roles, and patient perceptions and preferences also influenced how APPs are developed, integrated and retained.ConclusionsWe summarised a wide range of factors influencing APP role development and management in secondary care teams. We highlighted the importance for organisations to develop context-specific workforce solutions and strategies with long-term investment, significant resource input and transparent processes to tackle evolving healthcare challenges.

Communicate to Care: Implementing Health Literacy in a Pediatric Ears, Nose, and Throat Clinic.

Despite positive outcomes in controlled trials, organizations have been slow to adopt health literacy practices. The purpose of the Communicate to CARE (Clear Communication, Achieve Understanding with Teach-Back, Receptive to our patient family needs, Empathetic care delivery) study was to use theories and strategies from implementation science to scale up health literacy practices in a pediatric Ears, Nose, and Throat (ENT) clinic. Expanding on previous efforts that simply reflected on barriers, the CARE team identified barriers within the local context pre-implementation to select strategies to directly address barriers during health literacy implementation. The RE-AIM framework was used to evaluate the reach, effectiveness, adoption, implementation, and maintenance of health literacy practices. Over 18 months, the CARE team delivered multiple implementation strategies, including external facilitator, microlessons, preparing champions, audit and feedback, local consensus discussions, and small test of change. We tailored health literacy practices to clinic team roles to accommodate the clinic workflow. ENT team mean ratings on acceptability, appropriateness, and feasibility remained >4 indicating a high likelihood of successful implementation. Caregiver always ratings significantly increased from baseline to 12 months for easy-to-understand medication instructions (74%-96%), test results (54%-96%), know what to do if had questions (89%-96%), and encouraged to talk about health problems (76%-90%). Caregiver ratings dropped slightly at 18 months, indicating a need for booster training. While one third of caregivers reported Teach-Back practice across all time periods, the ENT team reported increased practice from baseline (42%), 6 (61%) and 12 months (70%). Over the first 12 months, the external facilitator delivered implementation strategies with weekly contact, tapering contact over the final 6 months. The local champion became engaged in the CARE study through a quality improvement project with meaningful outcomes for the clinic and an incentivization program for scholarly endeavors. Lunch and learn sessions helped build relationships between the CARE and ENT team to discuss and problem solve issues. The 5-item CAHPS health literacy composite proved to be sensitive to changes during implementation of health literacy practices. Integrating these items into standard follow up surveys with patients and families would help realize the return on investment for health literacy implementation. [HLRP: Health Literacy Research and Practice. 2024;8(3):e166-e174.].

Nuclear medicine technologists practice impacted by AI denoising applications in PET/CT images

PurposeArtificial intelligence (AI) in positron emission tomography/computed tomography (PET/CT) can be used to improve image quality when it is useful to reduce the injected activity or the acquisition time. Particular attention must be paid to ensure that users adopt this technological innovation when outcomes can be improved by its use. The aim of this study was to identify the aspects that need to be analysed and discussed to implement an AI denoising PET/CT algorithm in clinical practice, based on the representations of Nuclear Medicine Technologists (NMT) from Western-Switzerland, highlighting the barriers and facilitators associated. MethodsTwo focus groups were organised in June and September 2023, involving ten voluntary participants recruited from all types of medical imaging departments, forming a diverse sample of NMT. The interview guide followed the first stage of the revised model of Ottawa of Research Use. A content analysis was performed following the three-stage approach described by Wanlin. Ethics cleared the study. ResultsClinical practice, workload, knowledge and resources were de 4 themes identified as necessary to be thought before implementing an AI denoising PET/CT algorithm by ten NMT participants (aged 31–60), not familiar with this AI tool. The main barriers to implement this algorithm included workflow challenges, resistance from professionals and lack of education; while the main facilitators were explanations and the availability of support to ask questions such as a “local champion”. ConclusionTo implement a denoising algorithm in PET/CT, several aspects of clinical practice need to be thought to reduce the barriers to its implementation such as the procedures, the workload and the available resources. Participants emphasised also the importance of clear explanations, education, and support for successful implementation. Implications for practiceTo facilitate the implementation of AI tools in clinical practice, it is important to identify the barriers and propose strategies that can mitigate it.

Capitalizing on Implementation Science to Advance Antimicrobial Stewardship and Health Equity in Treating Pediatric UTI’s

Background: Pediatric urinary tract infections represent the most common pediatric infection with increasing gram-negative antibiotic resistance. Overutilization of antimicrobials including third generation cephalosporins are known drivers of this resistance. Antimicrobial stewardship (AS) efforts have recently shown that antibiotic selection may be influenced by patient race. Implementation science (IS) can provide frameworks and strategies to improve antimicrobial utilization and equity. Methods: This was a pre/post study of 2 geographically different children’s hospitals general pediatric floors assessing the impact of a set of implementation strategies developed to improve provider knowledge of best practice antimicrobials (based on local susceptibilities for treatment of UTI’s) and influence uptake of best practice prescribing. IS strategies included provider education, local clinical champion and opinion leader involvement, leadership involvement, local policy changes, and stakeholder co-design of decision support tools (a clinical pathway, a specific ITI antibiogram, and a dynamic order set). No education was provided regarding racial differences in prescribing habits. Outcomes were measured utilizing a portion of the RE-AIM Framework of assessing adoption of “Right” antibiotic, order set adoption, and equitable reach (racial differences in prescribing). Results: Hospital A and B had a first-generation cephalosporin prescription rate of 29.7% (n=441) and 20.6% (n-557) pre implementation and 44.6% (n=84) and 47.5% (n=118) post (p &lt; 0 .001). Both hospitals also saw a significant reduction in third-generation cephalosporins. In Hospital A, APRN’s were more likely to prescribe a first generation cephalosporin (52.4%) than a DO (42.1%) or MD (26.4%) pre-implementation (p=0.004). In Hospital B, APRN’s were less likely to prescribe first generation cephalosporins (5.4%) than a DO (28.9%) or MD (19.4%) pre-implementation (p=0.004). No statistical significance was seen post implementation for antimicrobial selection by provider type for either hospital. Based on race, both hospitals had Black and Other patients receiving more first-generation cephalosporins while white patients were more likely to receive third-generation cephalosporins (p=0.033) pre implementation. No statistical significance was seen post implementation for antimicrobial selection based on race. No improvement was seen in order set utilization. Conclusion: With order set utilization not improving with implementation of new dynamic order set, other strategies such as education, clinical champion and opinion leader involvement, and provision of a local UTI antibiogram were likely contributors to the improvement in best antimicrobial for treatment of UTI’s. Further mixed method research is warranted to improve understanding of the relative performance of our strategies, especially the lack of provider adoption of the novel dynamic order set.Disclosure: Jessica Snowden: Advisory board - Pfizer

Flexible endoscopic intubation in emergency medicine: A mixed-methods needs assessment.

This needs assessment aimed to improve understanding of flexible endoscopic intubation training and practice in emergency medicine (EM), providing insights to educators and practice leaders seeking to improve education and practices. We conducted a multicenter, mixed-methods needs assessment of emergency physicians (EPs) incorporating focus groups and a survey. Focus groups comprised community EPs, academic EPs, and resident EPs. We analyzed focus group transcripts using grounded theory, qualitatively describing EM endoscopic intubation. The qualitative analysis shaped our survey instrument, which we deployed in cross-sectional fashion. We report survey data with descriptive statistics. Focus groups with 13 EPs identified three themes: indications for use of endoscopic intubation, factors impacting a physician's decision to endoscopically intubate, and attaining and maintaining endoscopic intubation competency. Of 257 surveyed EPs (33% response rate), 79% had received endoscopic intubation training during residency, though 82% had performed this procedure 10 or fewer times in their career. Despite 97% acknowledging the necessity of competency, only 23% felt highly confident in their ability to perform endoscopic intubation. Participants (93%) reported scarce opportunities to perform the procedure and identified factors believed to facilitate competency acquisition and maintenance, including opportunities to perform endoscopic intubation in practice (98%), local champions (93%), and performing nasopharyngoscopy (87%). While most EPs acknowledged the importance of competency in endoscopic intubation, they reported scarce procedural opportunities and commonly expressed low confidence. Further research is needed on this topic, and we propose avenues to enhance education and practices related to endoscopic intubation. These include development of robust procedural curricula, support of local champions, and incorporating nasopharyngoscopy into EM practice.

Interventions for improving critical care in low- and middle-income countries: a systematic review.

To systematically review the typology, impact, quality of evidence, barriers, and facilitators to implementation of Quality Improvement (QI) interventions for adult critical care in low- and middle-income countries (LMICs). MEDLINE, EMBASE, Cochrane Library and ClinicalTrials.gov were searched on 1st September 2022. The studies were included if they described the implementation of QI interventions for adult critical care in LMICs, available as full text, in English and published after 2000. The risks of bias were assessed using the ROB 2.0/ROBINS-I tools. Intervention strategies were categorised according to a Knowledge Translation framework. Interventions' effectiveness were synthesised by vote counting and assessed with a binomial test. Barriers and facilitators to implementation were narratively synthesisedusing the Consolidated Framework for Implementation Research. 78 studies were included. Risk of bias was high. The most common intervention strategies were Education, Audit & Feedback (A&F) and Protocols/Guidelines/Bundles/Checklists (PGBC). Two multifaceted strategies improved both process and outcome measures: Education and A&F (p = 0.008); and PGBC with Education and A&F (p = 0.001, p < 0.001). Facilitators to implementation were stakeholder engagement, organisational readiness for implementation, and adaptability of interventions. Barriers were lack of resources and incompatibility with clinical workflows. The evidence for QI in critical care in LMICs is sparse and at high risk of bias but suggests that multifaceted interventions are most effective. Co-designing interventions with and engaging stakeholders, communicating relative advantages, employing local champions and adapting to feedback can improve implementation. Hybrid study designs, process evaluations and adherence to reporting guidelines would improve the evidence base.

Factors influencing uptake of protective behaviours by healthcare workers in England during the COVID-19 pandemic: A theory-based mixed-methods study.

Hospital infection control policies protect patients and healthcare workers (HCWs) and limit the spread of pathogens, but adherence to COVID-19 guidance varies. We examined hospital HCWs' enactment of social distancing and use of personal protective equipment (PPE) during the COVID-19 pandemic, factors influencing these behaviours, and acceptability and feasibility of strategies to increase social distancing. An online, cross-sectional survey (n = 86) and semi-structured interviews (n = 22) with HCWs in two English hospitals during the first wave of the COVID-19 pandemic (May-December 2020). The Capability, Opportunity, Motivation (COM-B) model of behaviour change underpinned survey and topic guide questions. Spearman Rho correlations examined associations between COM-B domains and behaviours. Interviews were analysed using inductive and deductive thematic analysis. Potential strategies to improve social distancing were selected using the Behaviour Change Wheel and discussed in a stakeholder workshop (n = 8 participants). Social distancing enactment was low, with 85% of participants reporting very frequently or always being in close contact with others in communal areas. PPE use was high (88% very frequently or always using PPE in typical working day). Social distancing was associated with Physical Opportunity (e.g., size of physical space), Psychological Capability (e.g., clarity of guidance), and Social Opportunity (e.g., support from managers). Use of PPE was associated with Psychological Capability (e.g., training), Physical Opportunity (e.g., availability), Social Opportunity (e.g., impact on interactions with patients), and Reflective Motivation (e.g., beliefs that PPE is effective). Local champions and team competition were viewed as feasible strategies to improve social distancing. It is valuable to understand and compare the drivers of individual protective behaviours; when faced with the same level of perceived threat, PPE use was high whereas social distancing was rarely enacted. Identified influences represent targets for intervention strategies in response to future infectious disease outbreaks.

Aligning peripheral intravenous catheter quality with nursing culture-A mixed method study.

To explore barriers and facilitators that influence adherence to evidence-based guidelines for peripheral intravenous catheter care in different hospital wards. Sequential explanatory mixedmethod study design, with qualitative data used to elaborate on quantitative findings. Data were collected between March 2021 and March 2022 using the previously validated Peripheral Intravenous Catheter mini questionnaire (PIVC-miniQ) on each ward in a tertiary hospital in Norway. Survey completion was followed by individual interviews with nurses from selected wards. The Pillar Integration Process was used to integrate and analyse the quantitative and qualitative findings. The PIVC-miniQ screening assessed 566 peripheral intravenous catheters in 448 patients in 41 wards, and we found variation between wards in the quality of care. Based on the quantitative variation, we interviewed 24 nurses on wards with either excellent or not as good quality. The integration of the quantitative and qualitative findings in the study enabled an understanding of factors that influence nurses' adherence to the care of peripheral venous catheters. One main theme and four subthemes emerged. The main finding was that ward culture affects education practice, and this was evident from four subthemes: (1) Deviation from best practice, (2) Gaps in education and clinical training, (3) Quality variation between wards and (4) The importance of supportive leadership. This mixed method study is the first study to explore reasons for variability in peripheral intravenous catheter quality across hospital wards. We found that ward culture was central to catheter quality, with evidence of deviations from best practice correlating with observed catheter complications. Ward culture also impacted nursing education, with the main responsibility for learning peripheral intravenous catheter management left to students' clinical training placements. Addressing this educational gap and fostering supportive leadership, including champions, will likely improve peripheral intravenous catheter care and patient safety. Nurses learn good peripheral intravenous catheter care in wards with supportive leaders and champions. This implies that the quality of nursing practice and patient outcomes are situational. Nurses need a strengthened emphasis on peripheral catheter quality in the undergraduate curriculum, and nurse leaders must emphasize the quality of catheter care in their wards. The study findings impact nurse leaders who must commit to quality and safety outcomes by appointing and supporting local ward champions for promoting peripheral intravenous catheter care. This also impacts nursing education providers, as the emphasis on catheter care must be strengthened in the undergraduate nursing curriculum and continually reinforced in the hospital environment, particularly when guidelines are updated. The study adhered to the Good Reporting of A Mixed Method Study (GRAMM). A patient representative has been involved in planning this study.