Novel methodology to measure pre-procedure antimicrobial prophylaxis: integrating text searches with structured data from the Veterans Health Administration’s electronic medical record

Mull, Hillary J.; Stolzmann, Kelly; Kalver, Emily; Shin, Marlena; Schweizer, Marin L.; Asundi, Archana; Mehta, Payal; Stanislawski, Maggie A.; Branch‐Elliman, Westyn

doi:10.1186/s12911-020-1031-5

Cited by 4 publications

(6 citation statements)

References 23 publications

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“…Three large volume, VA medical centers were selected based on (1) high volume of procedures (e.g., >100 procedures per year), (2) high rates of inappropriate antimicrobial use (>50%), and (3) operating characteristics of all elements of the semi-automated surveillance tools during the development and validation of the electronic monitoring tool that will be used for the audit-and-feedback reports [ 13 , 34 ].…”

Section: Study Design and Methodsmentioning

confidence: 99%

“…Monthly reports developed on previously published semi-automated electronic data extraction algorithms [ 34 ] that include concordance with guideline-based antimicrobial use practices at the facility and benchmarked to practices from the entire VA healthcare system, cardiac device infections and rate, and non-cardiac adverse events (AKI, C. difficile infections) will be provided to the local champions via the secured shared site. Thus, the information will be available for monthly conferences.…”

Section: Study Design and Methodsmentioning

confidence: 99%

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Promoting de-implementation of inappropriate antimicrobial use in cardiac device procedures by expanding audit and feedback: protocol for hybrid III type effectiveness/implementation quasi-experimental study

et al. 2022

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Background Despite a strong evidence base and clinical guidelines specifically recommending against prolonged post-procedural antimicrobial use, studies indicate that the practice is common following cardiac device procedures. Formative evaluations conducted by the study team suggest that inappropriate antimicrobial use may be driven by information silos that drive provider belief that antimicrobials are not harmful, in part due to lack of complete feedback about all types of clinical outcomes. De-implementation is recognized as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excess antimicrobial use following cardiac device procedures; however, investigations into strategies that lead to successful de-implementation are limited. The overarching hypothesis to be tested in this trial is that a bundle of implementation strategies that includes audit and feedback about direct patient harms caused by inappropriate prescribing can lead to successful de-implementation of guideline-discordant care. Methods We propose a hybrid type III effectiveness-implementation stepped-wedge intervention trial at three high-volume, high-complexity VA medical centers. The main study intervention (an informatics-based, real-time audit-and-feedback tool) was developed based on learning/unlearning theory and formative evaluations and guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) Framework. Elements of the bundled and multifaceted implementation strategy to promote appropriate prescribing will include audit-and-feedback reports that include information about antibiotic harms, stakeholder engagement, patient and provider education, identification of local champions, and blended facilitation. The primary study outcome is adoption of evidence-based practice (de-implementation of inappropriate antimicrobial use). Clinical outcomes (cardiac device infections, acute kidney injuries and Clostridioides difficile infections) are secondary. Qualitative interviews will assess relevant implementation outcomes (acceptability, adoption, fidelity, feasibility). Discussion De-implementation theory suggests that factors that may have a particularly strong influence on de-implementation include strength of the underlying evidence, the complexity of the intervention, and patient and provider anxiety and fear about changing an established practice. This study will assess whether a multifaceted intervention mapped to identified de-implementation barriers leads to measurable improvements in provision of guideline-concordant antimicrobial use. Findings will improve understanding about factors that impact successful or unsuccessful de-implementation of harmful or wasteful healthcare practices. Trial registration ClinicalTrials.govNCT05020418

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Section: Study Design and Methodsmentioning

confidence: 99%

Section: Study Design and Methodsmentioning

confidence: 99%

Promoting de-implementation of inappropriate antimicrobial use in cardiac device procedures by expanding audit and feedback: protocol for hybrid III type effectiveness/implementation quasi-experimental study

et al. 2022

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“…5,21,22 Then, this list will be used to develop electronic measurement tools. Based on our prior work, 23 we will develop each algorithm to detect SCIP INF-1 and 3 antimicrobial prophylaxis iteratively over several stages, by varying 1) types of variables included in the tool (e.g., text note extraction only, orders only, administration only, or combinations of the three), 2) timing of the searches (e.g., including or excluding the procedure date), and 3) types of antimicrobials included in the tool. The list will be used to search clinical notes for documentation of antibiotic administration pre-and/or post-operatively to measure compliance with SCIP metrics.…”

Section: Quantitative Data Collection and Analysismentioning

confidence: 99%

Assessing the Sustainability of Compliance with Surgical Site Infection Prophylaxis After Discontinuation of Mandatory Active Reporting: Study Protocol

Branch‐Elliman

Elwy

Lamkin

et al. 2022

Preprint

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BackgroundSurgical site infections are common. Risk can be reduced substantially with appropriate pre-operative antimicrobial administration. In 2005, the VA implemented the Surgical Care Improvement Project (SCIP) in the setting of high rates of non-compliance with antimicrobial prophylaxis guidelines. SCIP included public reporting of evidenced-based antimicrobial guideline compliance metrics in high-risk surgeries. SCIP was highly successful and led to high rates of adoption of pre-operative antimicrobials and early discontinuation of post-operative antimicrobials (> 95%). The program was retired in 2015, as the manual measurement and reporting process was costly with limited expected additional benefit. No studies have assessed whether the gains achieved by SCIP were sustained since discontinuation of active support for the program was discontinued. Furthermore, there has been no investigation of the spread of antimicrobial prophylaxis guideline adoption beyond the limited set of procedures that were included in the program.MethodsUsing a mixed methods sequential exploratory approach, this study will 1) quantitatively measure compliance with SCIP metrics over time and across all procedures in the five major surgical specialties targeted by SCIP, and 2) collect qualitative data from stakeholders to identify strategies that were effective for sustaining compliance. Diffusion of Innovation Theory will guide assessment of whether improvements achieved spread to procedures not included under the umbrella of the program. Electronic algorithms to measure SCIP antimicrobial use will be adapted from previously developed methodology. These highly novel data mining algorithms leverage the rich VA electronic health record and capture structured and text data and represent a substantial technological advancement over costly manual chart review or incomplete electronic surveillance based on pharmacy data. An interrupted time series analysis will be used to assess whether SCIP compliance was sustained following program discontinuation. Generalized linear models will be used to assess whether compliance with appropriate prophylaxis increased in all SCIP targeted and non-targeted procedures by specialty over the duration the program’s active reporting. The Dynamic Sustainability Framework will guide the qualitative methods to assess intervention, provider, facility, specialty, and contextual factors associated with sustainability over time. Barriers and facilitators to sustainability will be mapped to implementation strategies and the study will yield an implementation playbook to guide future sustainment efforts.RelevanceSustainability of practice change has been described as one of the most important, but least studied areas of clinical medicine. Learning how practices spread is also a critically important area of investigation. This study will use novel informatics strategies to evaluate factors associated with sustainability following removal of active policy surveillance and advance our understanding about these important, yet understudied, areas.RegistrationNot applicable.

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“…Study Setting: Three large volume, VA medical centers were selected based on: 1) high volume of procedures (e.g., >100 procedures per year), 2) high rates of inappropriate antimicrobial use (>50%), and 3) operating characteristics of all elements of the semi-automated surveillance tools during the development and validation of the electronic monitoring tool that will be used for the audit-and-feedback reports. 13,34 Study Design: A stepped-wedge implementation/effectiveness trial will be conducted at three VA medical centers.…”

Section: Blended Facilitationmentioning

confidence: 99%

“…Monthly reports developed on previously published semi-automated electronic data extraction algorithms 34 that include concordance with guideline-based antimicrobial use practices at the facility and benchmarked to practices from the entire VA healthcare system, cardiac device infections and rate, and non-cardiac adverse events (AKI, C. di cile infections) will be provided to the local champions via the secured shared site. Thus, the information will be available for monthly conferences.…”

Section: Phases Of the Stepped/wedge Designmentioning

confidence: 99%

Promoting De-Implementation of Inappropriate Antimicrobial Use in Cardiac Device Procedures By Expanding Audit and Feedback: Protocol for Hybrid III Type Effectiveness/ Implementation Quasi-Experimental Study

Branch‐Elliman

Lamkin

Shin

et al. 2021

Preprint

Self Cite

View full text Add to dashboard Cite

Background: Despite a strong evidence base and clinical guidelines specifically recommending against prolonged post-procedural antimicrobial use, studies indicate that the practice is common following cardiac device procedures. Formative evaluations conducted by the study team suggest that inappropriate antimicrobial use may be driven by information silos that drive provider belief that antimicrobials are not harmful, in part due to lack of complete feedback about all types of clinical outcomes. De-implementation is recognized as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excess antimicrobial use following cardiac device procedures; however, investigations into strategies that lead to successful de-implementation are limited. The overarching hypothesis to be tested in this trial is that a bundle of implementation strategies that includes audit and feedback about direct patient harms caused by inappropriate prescribing can lead to successful de-implementation of guideline-discordant care.Methods: We propose a Hybrid Type III effectiveness-implementation stepped-wedge intervention trial at three high-volume, high-complexity VA medical centers. The main study intervention (an informatics-based, real-time audit-and-feedback tool) was developed based on learning/unlearning theory and formative evaluations and guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) Framework. Elements of the bundled and multifaceted implementation strategy to promote appropriate prescribing will include audit-and-feedback reports that include information about antibiotic harms, stakeholder engagement, patient and provider education, identification of local champions, and blended facilitation. The primary study outcome is adoption of evidence-based practice (de-implementation of inappropriate antimicrobial use). Clinical outcomes (cardiac device infections, acute kidney injuries and Clostridioides difficile infections) are secondary. Qualitative interviews will assess relevant implementation outcomes (acceptability, adoption, fidelity, feasibility).Discussion: De-implementation theory suggests that factors that may have a particularly strong influence on de-implementation include strength of the underlying evidence, the complexity of the intervention, and patient and provider anxiety and fear about changing an established practice. This study will assess whether a multifaceted intervention mapped to identified de-implementation barriers leads to measurable improvements in provision of guideline-concordant antimicrobial use. Findings will improve understanding about factors that impact successful or unsuccessful de-implementation of harmful or wasteful healthcare practices.Trial Registration: Clinicaltrials.gov (NCT05020418)

show abstract

Novel methodology to measure pre-procedure antimicrobial prophylaxis: integrating text searches with structured data from the Veterans Health Administration’s electronic medical record

Cited by 4 publications

References 23 publications

Promoting de-implementation of inappropriate antimicrobial use in cardiac device procedures by expanding audit and feedback: protocol for hybrid III type effectiveness/implementation quasi-experimental study

Promoting de-implementation of inappropriate antimicrobial use in cardiac device procedures by expanding audit and feedback: protocol for hybrid III type effectiveness/implementation quasi-experimental study

Assessing the Sustainability of Compliance with Surgical Site Infection Prophylaxis After Discontinuation of Mandatory Active Reporting: Study Protocol

Promoting De-Implementation of Inappropriate Antimicrobial Use in Cardiac Device Procedures By Expanding Audit and Feedback: Protocol for Hybrid III Type Effectiveness/ Implementation Quasi-Experimental Study

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