Stewardship Role Research Articles

How are regulatory oversight organisations using long-term care performance indicators: a qualitative descriptive study in 10 high-income countries

ObjectivesRegulatory oversight organisations play an important role in quality stewardship in long-term care (LTC) facilities. Performance indicators are a key tool for any quality-related work. Our aim was to better...

Health Care and Climate Change—Telemedicine’s Role in Environmental Stewardship

Health Care and Climate Change—Telemedicine’s Role in Environmental Stewardship

Chronic hypoxia prolongs postoperative mechanical ventilation and reduces the left atrial pressure threshold in children with tetralogy of Fallot.

Chronic hypoxia induces pulmonary microvascular endothelial dysfunction. The left atrial pressure (LAP) represents the hydrostatic pressure of pulmonary microcirculation. The conjunction of the LAP and any abnormal pulmonary microvascular endothelial barrier function will have an impact on pulmonary exudation, resulting in prolonged mechanical ventilation. This study aimed to investigate the tolerance threshold of the pulmonary microcirculation to LAP in children with tetralogy of Fallot (TOF) to avoid prolonged mechanical ventilation after surgery. This retrospective study included 297 Chinese patients who underwent TOF correction at Fuwai Hospital. Patients were categorized according to their preoperative oxygen saturation (SpO2) level. One-to-one propensity score matching (PSM) revealed a total of 126 participants in the SpO2 < 90% and SpO2 ≥ 90% groups. Between-group comparisons were conducted to verify the correlation between hypoxia and prolonged mechanical ventilation. A subgroup analysis was performed to reveal the significant role of postoperative LAP stewardship on prolonged mechanical ventilation. Failure to extubate within the first 48 h (23.81% vs. 9.52%, P = 0.031) and prolonged mechanical ventilation (26.98% vs. 11.11%, P = 0.023) were more commonly observed in children with preoperative SpO2 < 90%. The incidence of prolonged mechanical ventilation consistently increased with LAP in both the SpO2 < 90% and SpO2 ≥ 90% groups, although LAP was still within the normal range (6-12 mmHg). Children in chronic hypoxic conditions tolerated lower LAP well. The tolerance threshold for postoperative LAP in children diagnosed with TOF under chronic hypoxic conditions was identified as 7 mmHg. Children in a chronic hypoxic state may suffer from a high incidence of prolonged mechanical ventilation after surgical correction of TOF and may not tolerate higher postoperative LAP. To improve pulmonary prognosis, it is better to control and maintain the postoperative LAP at a lower state (≤7 mmHg) in children with chronic hypoxia.

Remdesivir use and antimicrobial stewardship restrictions during the coronavirus disease 2019 (COVID-19) pandemic in the United States: A cross-sectional survey.

Deploying therapeutics for coronavirus disease 2019 (COVID-19) has proved challenging due to evolving evidence, supply shortages, and conflicting guideline recommendations. We conducted a survey on remdesivir use and the role of stewardship. Use differs significantly from guidelines. Hospitals with remdesivir restrictions were more guideline concordant. Formulary restrictions can be important for pandemic response.

Role of diagnostic stewardship in reducing healthcare-facility-onset Clostridioides difficile infections.

We describe the implementation of an electronic medical record "hard stop" to decrease inappropriate Clostridioides difficile testing across a 5-hospital health system, effectively reducing the rates of healthcare-facility-onset C. difficile infection. This novel approach included expert consultation with medical director of infection prevention and control for test-order override.

Antimicrobial stewardship and drug formulary restrictions during COVID-19: what is restricted and who decides?

COVID-19 therapies were challenging to deploy due to evolving literature and conflicting guidelines. Antimicrobial stewardship can help optimize drug use. We conducted a survey to understand the role of stewardship and formulary restrictions during the pandemic. Restrictions for COVID-19 therapies were common and approval by infectious disease physicians often required.

Nurse prescriber's understanding of their antimicrobial stewardship role: a qualitative study.

Introduction Antimicrobial resistance is an infectious disease threat to public health globally, and antimicrobial stewardship among healthcare professionals is one key way to address this potential problem. Registered nurse designated prescribers are the newest group of health professionals to gain prescribing authority in Aotearoa New Zealand, yet little is known about their understanding of their antimicrobial stewardship role. Aim The aim of this study was to explore registered nurse designated prescribers' understanding of their antimicrobial stewardship role through their prescribing practices and approaches to clinical reasoning. Methods This exploratory descriptive qualitative study used individual semi-structured interviews with six registered nurse designated prescribers. Thematic analysis was used to analyse the interviews. Results Four themes were identified: antibiotic prescribing practices and antimicrobial resistance; clinical indicators for prescribing antibiotics, with the sub-themes of history taking, presence of infection and bacterial versus viral infection; patient education; and safety and monitoring. These themes provide insight into registered nurse designated prescribers' understanding of their antimicrobial stewardship role and prescribing of antibiotics. Discussion This research found that the registered nurse designated prescribers had an awareness of the importance of their antimicrobial stewardship role in relation to antibiotic prescribing and reducing antimicrobial resistance. Education about antimicrobial resistance and antimicrobial stewardship for this professional group can be effective, but further research is needed to understand their ongoing educational needs.

A Critical Investigation of Factors Influencing Ugandan Family-Owned Manufacturing Businesses’ Performance

Objective: This study investigated the role of resources, capabilities, entrepreneurial orientation, and stewardship on the performance of family-owned manufacturing businesses in Uganda to establish how a firm can identify the rare and valuable resources that simultaneously enable better performance levels and competitive advantage. Research Design &amp; Methods: A qualitative study with 15 participants from six family manufacturing businesses using interviews. The transcribed data was analysed and grouped into themes. Findings: General management skills, financial management, marketing management, and technology benefits are key resources and capabilities that enhance the smooth operations of the family manufacturing businesses and play are pivotal in achieving better performance and sustainability. Secondly, it was found that proactiveness, risk management, and continuous evaluation and appraisals of their performance were practised among family-owned manufacturing businesses. Thirdly, decision-making systems and lines of authority, enabling them to constantly analyse market trends and know about competitors were in place. Lastly, although there are supporting programmes for the manufacturing industries to help family-owned manufacturing businesses acquire start-up resources and import raw materials, there still needs to be more consistency in implementing such support programmes in Uganda. Implications &amp; Recommendations: Family business owners should embrace proactivity, risk management, and continuous evaluation and appraisals of business performance. Furthermore, a review of current government policies, particularly those about industry financing and labour management, is recommended. Contribution &amp; Value Added: The study was the first attempt to examine the performance of family-owned manufacturing businesses in Uganda. An improved framework was developed for their entrepreneurial success.

Nurses' perceptions of the potential evolution of their role in antibiotic stewardship in nursing homes: a French qualitative study.

In nursing homes, infections and antibiotic prescriptions are frequent. Nursing home nurses (NHNs) and advanced practice registered nurses (APRNs) could promote antibiotic stewardship (ABS). Few studies have explored nurses' knowledge, perceptions and practices towards ABS in nursing homes and none has investigated the potential evolution of their roles. To explore French nurses' perceptions on ABS, current and future potential roles in ABS in nursing homes, as well as facilitators and barriers. We conducted a qualitative study in north-eastern France between October 2020 and March 2021 using semi-structured individual interviews with NHNs and a focus group with APRNs. Transcripts of the interviews were analysed using a thematic analysis. Twenty NHNs and seven APRNs participated. They were aware of antibiotic misuse and potential adverse events but lacked knowledge on some ABS aspects. NHNs' current ABS roles ranged from the detection of clinical infectious signs to clinical monitoring of residents, with some heterogeneity between nurses. They had positive opinions towards playing a more prominent role in ABS. In the future, with additional training, changes in the legislative framework and greater multidisciplinary teamwork, NHNs thought they could prescribe laboratory microbiological analyses and some targeted antibiotic treatments. APRNs thought they could prescribe first-line antibiotics for urinary tract infections. French NHNs' current ABS roles could be expanded and new roles might be considered while taking into account several facilitators and barriers. According to APRNs, they could help to compensate for the limited presence of doctors in nursing homes and develop infectious diseases skills.

164. BioFire FilmArray Pneumonia Panel Implementation: Examining Appropriate Usage and Opportunities for Diagnostic Stewardship

Abstract Background The BioFire FilmArray Pneumonia Panel (PnaP) is a novel diagnostic tool for rapid diagnosis of lower respiratory tract infections. However, appropriate usage and optimal implementation strategy in the clinical setting remain poorly characterized. The PnaP assay was introduced along with institutional guidance restricting use to intensive care units (ICUs) and Infectious Disease and Pulmonary consultative services. Examining guideline compliance and clinically appropriate PnaP usage highlights the role of diagnostic stewardship in improving management of pneumonia in hospitalized patients. Methods PnaP testing was obtained retrospectively from hospitalized adults over a 6-month period (January 1 - June 30, 2021). Outpatient and pediatric (&amp;lt; 18 years of age) testing was excluded. Appropriate use criteria based on institutional guidance are defined in Figure 1. Primary outcomes included PnaP results with respect to utilization appropriateness. Statistical analyses included chi squared testing with p-value &amp;lt; 0.05 considered statistically significant. Results PnaP testing was performed on 574 respiratory samples from 440 patients (Table 1). Overall compliance with institutional guidance was 84% (n=482/574) but varied with respect to level of care (ICU 89% vs non-ICU 72%, p &amp;lt; 0.001) and location (Table 2). Repeated testing was the most common reason for non-compliance, accounting for 59% of inappropriate use. Positivity rates varied significantly respect to guideline compliance and level of care, with distinct pathogen isolation profiles seen among ICU and non-ICU patients. Pathogen isolations was not significantly impacted by respiratory sample type (Table 3). Conclusion Multiplex panels can isolate significant more pathogens compared to traditional diagnostic testing, with the potential to identify additional variables that factor into pneumonia pathology. PnaP assay results and appropriateness of use appear intertwined, with criteria compliance significantly impacting positivity rates, with distinct pathogens isolated among ICU and non-ICU patient groups. Our study highlights specific target areas for intervention, with the potential to promote clinically appropriate diagnostic testing by adjusting ordering restrictions at our hospital. Disclosures Trevor C. Van Schooneveld, MD, bioMerieux: Advisor/Consultant|bioMerieux: Grant/Research Support|Insmed: Grant/Research Support|Merck: Grant/Research Support|Thermo-Fischer: Advisor/Consultant.

1107. A Survey on Remdesivir Use and Antimicrobial Stewardship Restrictions Throughout the COVID-19 Pandemic

Abstract Background Remdesivir (RDV) was the first agent with proven clinical benefit against COVID-19, shortening the time to recovery in a randomized placebo-controlled trial (RCT). Based on this trial, the Food and Drug Administration approved RDV via emergency use authorization. Despite its wide use, RDV remains controversial. Early use of RDV in patients requiring low flow nasal canula has robust evidence. However, benefit in mechanical ventilation (MV), high-flow nasal canula (HFNC) and non-invasive positive pressure ventilation (NIPPV) is conflicting. Multiple studies, most notably the SOLIDARITY and DisCoVeRy trial, have conflicting results on who benefits from RDV. Deploying novel therapeutics in this changing landscape is challenging. We seek to understand RDV practices and the role of antimicrobial stewardship (ASP) in hospitals across the US. Methods A survey was developed and disseminated through Infectious Diseases Society of America (IDSA) IDea network, IDSA Antimicrobial Stewardship Centers for Excellence and the Society for Healthcare Epidemiology messaging boards. Data collected included city, presence of RDV therapeutic restrictions, and RDV use by degree of oxygen needs for each COVID-19 wave. Results A total of 78 responses were collected, representing wide geographic reach in the US (Figure 1). RDV was restricted in 53% of facilities. Hospitals without restrictions commonly used RDV for patients on MV, NIPPV and HFNC, with more use on HFNC than on NC during the first winter, Delta and Omicron waves (Figure 2). Use on MV declined with each surge. Hospitals with RDV restrictions had more use of RDV on NC than all other ordinal scales (Figure 3). Use in MV, NIPPV and HFNC compared to NC declined in the restricted group with each COVID-19 surge. Figure 1.Geographic distribution of hospitals represented in the survey Figure 2. Remdesivir use by oxygen requirements in hospitals without remdesivir therapeutic restrictions. Figure 3 Remdesivir use by oxygen requirements in hospitals without remdesivir therapeutic restrictions. Conclusion A wide gap between evidence-based guidelines and actual practice exists. This gap was wider in hospitals without COVID-19 therapeutic restrictions in place for RDV. In the unrestricted group, RDV was commonly used for MV, HFNC and NIPPV, where robust RCT evidence of benefit is lacking. Though this practice occurred in both groups, the restricted RDV group prioritized RDV use in NC and did so at higher percentages each subsequent COVID-19 surge. ASP restrictions can have an important role in guiding COVID-19 therapy. Disclosures All Authors: No reported disclosures.

963. Perceived Antimicrobial Stewardship Roles of Pharmacists and Residents in US Intensive Care Units

Abstract Background Antimicrobial stewardship programs (ASPs) were developed as a way of addressing antibiotic resistance by promoting the judicious use of antibiotics. Pharmacist and resident perspectives of their own roles within antimicrobial stewardship are relatively unknown. An ethnographic study of intensive care units (ICU) was conducted to understand the perceptions and attitudes surrounding pharmacist and resident roles relative to stewardship. Methods A research assistant with medical anthropology training performed semi-structured interviews with intensive care pharmacy specialists and residents at a medical center in Cleveland, Ohio, USA between June 2021 and August 2021. Data analysis centered on the understandings of ASPs and antibiotic prescribing present in multidisciplinary groups where certain members are not primary antibiotic decision-makers. The data were analyzed using thematic coding aided by NVivo qualitative analysis software. Results Intensive care pharmacy specialists (N=5) and residents (N=6) were interviewed, accruing &amp;gt; 518 minutes of semi-structured interview data. Pharmacy specialists described their contributing role as serving stewardship goals such as “decreasing mortality” and believed that they should have input in antibiotic decision making. Residents also emphasized the importance of consulting pharmacists before antibiotic decisions were made. Both groups felt limited in their ability to contribute to final antibiotic decisions. Pharmacists regularly referred to their input as a “recommendation” and described their actions as “suggestions”. Residents expressed that physicians were better suited to make decisions due to the residents’ limited experience, acknowledging that they “don’t know everything.” Table 1.Key Themes and Perceived Roles in Intensive Care Conclusion This study found that ICU pharmacists and residents have an awareness of stewardship that might aid in antimicrobial prescribing. Both groups expressed an appreciation for stewardship goals despite being bounded by hierarchies of medical practice. Providing these groups with greater autonomy over prescribing practices might improve ASP effectiveness. Future studies may focus on analysis on the social dynamics of hospital spaces and the corresponding impact on decision-making and expert practices. Disclosures All Authors: No reported disclosures.

Passive Investors and Audit Quality: Evidence from the U.S.

The rise of index funds, or passive investing, in recent decades has caused heated debates over the efficacy of passive investors' stewardship role in corporate governance. Our study adds to this emerging line of literature by examining whether passive investors enhance the quality of financial statement audits, a key aspect of corporate governance mechanisms. We exploit the yearly Russell index reassignment, which provides us with an ideal setting to study the causal relation between passive institutional investors (i.e., index trackers) and firms' audit quality. Examining firms closely surrounding the Russell 1000/2000 cutoff line, we find that higher passive ownership leads to higher audit quality proxied by audit fees. To investigate the channel through which passive investors influence audit-related governance issues, our evidence from auditor ratification voting records suggests that passive investors do ‘voice’ their opinion on low-quality audits. Such effort also leads to a higher likelihood of auditor turnover in the following year. In the cross-sectional analysis, we also find that the positive effect of passive investors on audit quality is more pronounced in firms with higher agency costs. Thus, our study supports the view that passive investors play an active role in improving corporate governance.

Exploring the Potential of Internal Information Flows in Large Organizations as Leverage Points for Environmental Stewardship

Large organizations play a critical role in environmental stewardship. The concept of leverage points offers one promising avenue of inquiry to enhance the effectiveness of large organizations in advancing environmental stewardship. Here, we focus on the flow of information within a large environmental organization as a deep leverage point for system change. We conducted a social network analysis of an organization with an environmental stewardship mandate. Results show that the organization has a dense communication network that could be effectively leveraged for environmental stewardship communication, especially by influential individuals and departments. As practical implications, we recommend that an environmental stewardship-focused communication approach, based on four strategies (segmentation, induction, two-way communication, and individual strategies) be enacted by the organization to use this leverage point to enhance the diffusion of environmental stewardship. Directions for future research include a deep study of the plurality of understandings of environmental stewardship within the organization.

Canadian Engineering Grand Challenges in co-curricular and online environment: Opportunities and Challenges

Engineering Deans Canada (EDC) recently articulated Grand Challenges that recognize the role of engineers and the specific needs of Canadians in the form of Canadian Engineering Grand Challenges (CEGCs). The CEGCs offer a unique framework to motivate and engage engineering students from different disciplines and encourage collaboration and the sharing of their discipline expertise. The CEGCs also offer a framework for engineering students to develop leadership skills and gain awareness of their technological, innovation and stewardship roles. In this paper, we report on a student-led approach in the online environment for the creation of two workshops and one “Leadathon” case competition related to the CEGCs and leadership skills development. The activities were developed and delivered by a team of engineering students with the support of faculty members. We refer to this student-led model as “for-students-by-students’. Feedback collected from student facilitators and participants indicate that the resulting activities were effective in engaging students and raising awareness of the CEGCs and of their role to address societal problems as future engineers. We present the methodology that was adopted to leverage and take advantage of the online environment, while addressing differences in participant interactions and engagement from the perspective of opportunities and challenges. Finally we discuss potential avenues to integrate into the mainstream curriculum for-student-by-student model related to the interaction with CEGCs.

Higher-Order Beliefs, Market-Based Incentives, and Information Quality

We investigate how interdependence among investors' beliefs affects the reliance on market prices as a performance measure and how this in turn affects the firm's preference for financial reporting quality. When investors want to align their values more with other investors' beliefs, optimal contracts become more reliant on the accounting report and less on the market price, emphasizing the stewardship role of accounting in a herding market. If the baseline accounting quality required by a reporting standard is high enough, the firm prefers to increase its accounting quality for the sake of contracting efficiency. However, if the baseline quality is low, the firm further lowers accounting quality for the same reason. The benchmark level that determines whether the firm prefers to increase accounting quality increases with the interdependence of investors' beliefs, implying that it is difficult to align the information and stewardship roles of accounting in a herding market.

How paediatricians communicate with parents who access online health information.

Recent years have seen an exponential increase in the proportion of parents searching for online health information on their child's medical condition. We investigated the experiences, attitudes and approaches of paediatricians interacting with parents who search for online health information and the impact on the doctor-parent relationship. This qualitative study was conducted utilising semi-structured interviews with 17 paediatric physicians, surgeons, anaesthetists and trainees working in an Australian children's hospital. Data were analysed through deductive and inductive thematic analysis using line-by-line coding. Three key themes were identified: paediatricians' experiences with, and attitudes towards, parents using online health information; paediatricians' communication approaches; and the perceived impact on the doctor-parent relationship. These themes demonstrated that most paediatricians acknowledged the information parents found and directed parents to reliable websites. Following discussions with Internet-informed parents, a few changed their management plans and a few reported discouraging parents from further searching online. Our results indicate that paediatricians predominantly used patient-centred communication strategies to care for patients in partnership with parents. Paediatricians contextualising online health information can contribute to a quality partnership with parents and facilitate shared decision-making, potentially fostering better health outcomes for children. Our conclusions may inform clinicians' communication approaches when interacting with Internet-informed parents and stimulate research about more effective doctor-parent communication approaches. In a digital age, paediatricians may benefit from employing more time-efficient approaches to manage increasing workloads with their new role of digital stewardship of parents.

The fog index in accounting research: contributions and challenges

PurposeThe objective of this paper is to review the use of the fog index in accounting research.Design/methodology/approachThis paper uses a systematic literature review (SLR) methodology with a sample of 126 accounting research articles. The review applies the theoretical framework of disclosure's stewardship, valuation and accountability roles to identify the contributions and challenges of using the fog index in accounting research.FindingsThis paper shows that the primary contribution of the fog index to accounting research relates to the disclosure obfuscation hypothesis (e.g. whether management obfuscates narratives associated with earnings). It also finds that the challenge in using the fog index is in disentangling its measure of firm environmental complexity from narrative obfuscation. Regarding disclosure utility, there is limited evidence on the differential effects of complexity on investor types and whether the fog index findings are associated with narrative obfuscation or firm environmental complexity is driven by investor types.Research limitations/implicationsThe authors develop a research database of fog index studies categorised based on contributions to disclosure obfuscation or disclosure utility, highlighting contributions to the stewardship, valuation and accountability roles of disclosures, which researchers can use to develop future studies.Originality/valueThis paper contributes to accounting literature by offering the first comprehensive review on the use of the fog index in accounting research. It offers researchers a consolidated review of the study of linguistic complexity of accounting information and disclosure functions using a theoretical framework that can inform regulators, policymakers and future researchers in designing future research/policy.

Diagnostic Stewardship in Times of COVID-19 Pandemic.

A cluster of unknown acute pneumonia cases by a novel coronavirus signaled an outbreak in Wuhan province of China in December 2019. The World Health Organization (WHO) initially declared COVID-19 as the global public health emergency on 30th January 2020 and subsequently a pandemic on March 11, 2020. It was also stated that the spread of COVID-19 may be interrupted by early detection, isolation, prompt treatment, and the implementation of a robust system to trace contacts. Testing is a key strategy and the role of Diagnostic Stewardship (DS) is essential to allocate and engage the present as well as new testing resources strategically, effectively, efficiently, and safely. Thus, diagnostic stewardship aims to select the right test for the right patient, at the right time to generate accurate, clinically relevant results which will optimally influence better clinical care outcomes and will conserve the available health care resources.

What limits Muslim communities’ access to nature? Barriers and opportunities in the United Kingdom

Recreation in protected areas can greatly contribute to health and wellbeing, but there exist significant demographic disparities in protected area use across Europe and North America. Minority ethnic groups, in particular, are often underrepresented in protected areas due to a variety of cultural, economic, and discriminatory barriers. Muslims are one of the fastest growing minority ethnic communities in Western countries but have received little study in the context of protected areas. More research is therefore needed to understand protected area exclusion as experienced by Muslim communities. Through 14 in-depth interviews with Muslim community leaders in the United Kingdom, we explored the socio-cultural barriers and opportunities that contribute to the accessibility of protected areas for Muslims. As the majority of our participants were women, this study addresses the underrepresentation of diverse female voices in research on Muslims and leisure and foregrounds Muslim women as agents in their recreational lives. We found that a wide variety of factors can inhibit access, cumulatively resulting in several layers of exclusion. Primary barriers included a lack of inclusive imagery, insufficient facilities for social gathering, prior instances of discrimination, the perceived whiteness of protected areas, and unfamiliarity with these spaces. Several barriers related to the wilderness ideology that is embedded across many aspects of protected area marketing, design, and management as it does not embrace collectivist aspects of Muslim cultures. The level of “naturalness” associated with protected areas, however, did not emerge as a barrier. We also identified many opportunities, including the stewardship role of humans depicted within Islam. Lastly, we discuss the management implications for protected areas that emerge from our results. This research demonstrates that to foster a sense of belonging for Muslim communities, protected area managers must consider many socio-cultural dimensions of accessibility, holistically engage with Muslim communities, and embrace diverse worldviews relating to the human–nature relationship.