Mary Jo Knobloch

Use of the Health Belief Model to Study Patient Perceptions of Antimicrobial Stewardship in the Acute Care Setting

OBJECTIVE To identify themes associated with patient perceptions of antibiotic use and the role of patients in inpatient antimicrobial stewardship. DESIGN We conducted semi-structured interviews with 30 hospitalized patients using the Health Belief Model as the framework for questions and analysis. SETTING An academic tertiary care hospital in Madison, Wisconsin. PARTICIPANTS A total of 30 general medicine inpatients receiving at least 1 anti-infective medication were interviewed. RESULTS Participants recognized antibiotic resistance as a serious public health threat but expressed low perceived susceptibility to being personally affected by antibiotic resistance. Views of susceptibility were influenced by a high degree of trust in physicians and misperceptions regarding the mechanisms underlying resistance. Participants expressed high self-efficacy and a desire to be involved in their health care. Perceived roles for patients in preventing the inappropriate use of antibiotics ranged from asking questions and speaking up about concerns to active involvement in decision making regarding antibiotic treatments. Few participants reported being offered the opportunity to engage in such shared decision making while hospitalized. CONCLUSIONS Our findings suggest an important role for patients in improving antibiotic use in hospitals. However, patient engagement has not been recognized as a critical component of antimicrobial stewardship programs. Our study suggests that the likelihood of patient engagement in stewardship practices is currently limited by low perceived susceptibility and lack of cues to act. Further investigation into how patients may be engaged as good stewards of antibiotics may reveal new ways to improve antibiotic prescribing practices in the inpatient setting.

Leadership rounds to reduce health care–associated infections

Background: Evidence‐based guidelines exist to reduce health care–associated infections (HAIs). Leadership rounds are one tool leaders can use to ensure compliance with guidelines, but have not been studied specifically for the reduction of HAIs. This study examines HAI leadership rounds at one facility. Methods: We explored unit‐based HAI leadership rounds led by 2 hospital leaders at a large academic hospital. Leadership rounds were observed on 19 units, recorded, and coded to identify themes. Themes were linked to the Consolidated Framework for Implementation Research and used to guide interviews with frontline staff members. Results: Staff members disclosed unit‐specific problems and readily engaged in problem‐solving with top hospital leaders. These themes appeared over 350 times within 22 rounds. Findings revealed that leaders used words that demonstrated fallibility and modeled curiosity, 2 factors associated with learning climate and psychologic safety. These 2 themes appeared 115 and 142 times, respectively. The flexible nature of the rounds appeared to be conducive for reflection and evaluation, which was coded 161 times. Conclusions: Each interaction between leaders and frontline staff can foster psychologic safety, which can lead to open problem‐solving to reduce barriers to implementation. Discovering specific communication and structural factors that contribute to psychologic safety may be powerful in reducing HAIs.

Research Agenda for Antimicrobial Stewardship in the Veterans Health Administration

Author(s): Suda, Katie J; Livorsi, Daniel J; Goto, Michihiko; Forrest, Graeme N; Jones, Makoto M; Neuhauser, Melinda M; Hoff, Brian M; Ince, Dilek; Carrel, Margaret; Nair, Rajeshwari; Knobloch, Mary Jo; Goetz, Matthew B

Incorporation of Leadership Rounds in CAUTI Prevention Efforts

Leadership engagement is an important aspect of integrating best practices at the bedside. The catheter-associated urinary tract infection (CAUTI) prevention workgroup at our academic medical center implemented leadership rounding in partnership with clinical staff to increase participation in CAUTI prevention initiatives on inpatient units. There was an associated decrease in urinary catheter utilization and CAUTI rates. Implementation of leadership rounds should be considered as a part of comprehensive CAUTI prevention efforts in health care settings.

Antimicrobial Stewardship: The Role of the Patient

Opinion StatementThe aim of this article is to describe the current state of the patient role in antimicrobial stewardship efforts. There is a global crisis in antimicrobial resistance (AR) for which antimicrobial use is the main driver. Antimicrobial stewardship (AS) is a critical ally in the battle against AR. The extent to which specific AS initiatives are implemented across settings varies considerably; many acute care settings have a formal antimicrobial stewardship program (ASP), but other patient care settings such as outpatient clinics or long-term care facilities are generally in the early phases of developing AS efforts which may include a regional approach encompassing transitions of care. In recognizing that a coordinated care approach across the spectrum of healthcare is essential to improve patient outcomes, there is a renewed and increased push to broaden AS implementation across multiple settings. In the acute care setting, a common characteristic of an ASP is a multidisciplinary team to guide antibiotic decision-making at an individual and a facility level. Efforts often target appropriate use of antimicrobials via formulary restrictions, prescribing decision-support models, education, and audit and feedback of prescribing practices. Patients are not usually included in stewardship efforts. Stewardship literature which includes a patient-role component is limited and focuses primarily on physician-patient communication or educational campaigns to raise public awareness of AS. There is little research exploring direct patient involvement in AS efforts, although there is some evidence that patients are aware of the implications of AR, its link to antimicrobial use, and its impact on health at the population level. Recent work has shown that patients believe there is a role for them in AS efforts; however, there is no guidance on the best approach to achieve patient involvement in AS initiatives and no evidence of the effect of such patient involvement on clinical outcomes. In order to fill the gap in knowledge related to the patient role in AS, we recommend the following for clinicians and researchers:• Increase patient awareness and understanding of AS and the impact on their care. This may be the first step in successfully involving patients in AS endeavors.• Identify situations in which patients can realistically become part of the AS movement across the healthcare spectrum. This would call for studying the process of patient recruitment and engagement and impact of adding the patient voice. This could also include studying patient perspectives about being involved in AS, along with clinician and researcher perspectives of involving patients.• Undertake research studies to examine different implementation strategies for involving patients and evaluate the effect of engagement on clinical outcomes relevant to AS such as decreased antibiotic usage and antibiotic resistance.

Patient perspectives on indwelling urinary catheter use in the hospital

Urinary tract infections are one of the most common hospital-acquired infections, with 70%-80% resulting from catheter-associated urinary tract infections (CAUTIs). We undertook a qualitative study to assess patient perspectives of indwelling urinary catheters using a semistructured interview. We found that patient awareness and patient engagement regarding indwelling urinary catheters and their consequences could be improved in the hospital setting. Implementing educational programs incorporating patient preferences for both health care workers and patients is likely to increase the involvement of patients in decision-making regarding urinary catheters and may lead to a decline in CAUTIs.

Community pharmacy interventions to improve antibiotic stewardship and implications for pharmacy education: A narrative overview

BACKGROUND Antibiotic resistance is one of the worlds most pressing public health problems, resulting in over 23,000 deaths per year. One of the main contributing factors to antimicrobial resistance is antibiotic misuse and overuse. Community pharmacists can play a role in reducing antibiotic resistance, since they are one of the most accessible healthcare professionals. OBJECTIVE The purpose of this paper is to describe community pharmacy interventions and strategies to reduce antibiotic misuse and overuse and to discuss the implications for pharmacy training. METHODS A narrative overview strategy was employed to identify papers on antibiotic stewardship and the role of the community pharmacist. Our review examined potential stewardship strategies and interventions within community pharmacy practice that provide opportunities for pharmacists to engage or lead in the reduction of antimicrobial resistance. RESULTS We describe five promising community pharmacist-led intervention strategies: Collaborative Practice Agreements (CPAs), point-of-care (POC) testing, patient consultations, academic detailing and serving as an advocate for patients and other healthcare providers CONCLUSIONS: This review highlights topics that may warrant increased attention in pharmacy school curricula. Pharmacy schools may want to consider modifying their curricula to address the shifts in practice of the community pharmacist - emphasizing the expanded role of the pharmacist in patient care and public health issues such as outpatient antibiotic stewardship.

Patients as stakeholders: Developing a patient-centered healthcare epidemiology research agenda

To the Editor—Due to its many benefits, stakeholder engagement in health research has been increasingly prioritized in recent years. Engagement throughout the research cycle, from idea development through dissemination of results, helps to ensure that research questions and outcomes are meaningful and relevant to stakeholders, and it may also improve research quality and appropriateness. Given the threat of healthcare-associated infections (HAIs) to patient safety, stakeholder engagement is critical in healthcare epidemiology. Effective HAI prevention and control require collaboration between multiple stakeholders: clinicians, other providers directly or indirectly involved in patient care, healthcare administrators, caregivers, and patients. Despite progress in understanding pathogens, epidemiology, and prevention and control mechanisms, many research gaps remain. Because patients and caregivers have not previously been involved as stakeholders in HAI research, their perspectives on these gaps are poorly understood. We believe that increasing the engagement of patients and caregivers in HAI research is necessary to address existing gaps in knowledge related to HAI prevention. To develop a patient-centered HAI research agenda, we convened a patient and caregiver stakeholder (PCS) group of 7 older adults (4 men, 3 women, most >50 years old) from Wisconsin. All members had experience as a patient or as a caregiver to a patient with an HAI, and 2 members had additional professional medical experience. Before discussing the research agenda, the PCS group members received initial training in HAI research, terminology, and concepts, and they participated in preparatory activities such as describing their perceptions of environmental contamination in a hospital room and meeting with institutional stakeholders to discuss HAI work. Research agenda discussions centered on a subset of strategies identified by the Society for Healthcare Epidemiology of America (SHEA): (1) evaluation of environment and equipment sources for infection; (2) compliance with and impact of contact precautions; (3) patient presurgical preparation; and (4) antibiotic stewardship, particularly the role of pharmacists. In consultation with the Wisconsin Network for Research Support (www.winrs.nursing.wisc.edu/), we designed an activity for stakeholders to identify their perceived individual (patient and/or caregiver) and provideror institutional-level barriers to implementing a strategy. Their ideas were elaborated through discussions with the research team, and the resulting barriers represent potential targets for intervention in future patientcentered HAI research (Table 1). Patient feedback provides important context to previously described HAI prevention research topics. For example, patients highlighted concern that care may be negatively impacted by asking providers about noncompliance with contact precaution protocols. While HAI research is often focused within healthcare settings, patients wanted to know the steps they could take outside the healthcare setting to reduce their risk of acquiring HAIs. However, the demographics of the PCS group may limit the generalizability of these results to other patient populations. These perspectives have been critical as we identify priority areas for investigation and as we engage patients in developing research projects to address these areas. We encourage other researchers to consult with patients and caregivers in setting their research agendas and to develop a patient-centered plan aligned with the needs of those who know the most about living with an HAI.

Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings

BackgroundInappropriate ordering and acquisition of urine cultures leads to unnecessary treatment of asymptomatic bacteriuria (ASB). Treatment of ASB contributes to antimicrobial resistance particularly among hospital-acquired organisms. Our objective was to investigate urine culture ordering and collection practices among nurses to identify key system-level and human factor barriers and facilitators that affect optimal ordering and collection practices.MethodsWe conducted two focus groups, one with ED nurses and the other with ICU nurses. Questions were developed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. We used iterative categorization (directed content analysis followed by summative content analysis) to code and analyze the data both deductively (using SEIPS domains) and inductively (emerging themes).ResultsFactors affecting optimal urine ordering and collection included barriers at the person, process, and task levels. For ED nurses, barriers included patient factors, physician communication, reflex culture protocols, the electronic health record, urinary symptoms, and ED throughput. For ICU nurses, barriers included physician notification of urinalysis results, personal protective equipment, collection technique, patient body habitus, and Foley catheter issues.ConclusionsWe identified multiple potential process barriers to nurse adherence with evidence-based recommendations for ordering and collecting urine cultures in the ICU and ED. A systems approach to identifying barriers and facilitators can be useful to design interventions for improving urine ordering and collection practices.

Patient perceptions of chlorhexidine bathing: A pilot study using the health belief model

HIGHLIGHTSInterviews revealed low perceived susceptibility to infection.Patients had low knowledge of the benefits of chlorhexidine.Most patients had low perceived self‐efficacy in preventing health care–associated infections. Background: Many studies investigating daily chlorhexidine gluconate (CHG) bathing as an infection control intervention to decrease health care–associated infections have focused on reduction of infection and colonization; few studies have assessed CHG bathing compliance, work system factors, facilitators, and barriers to implementation. Methods: This is a combination retrospective/prospective pilot study conducted at a large academic teaching hospital that implemented daily CHG bathing across all inpatient units. CHG compliance and patient refusal were calculated on the basis of documentation in the electronic medical record. We used the health belief model to guide semistructured interviews with patients about knowledge and barriers related to CHG bathing. Results: Of the 31 patients interviewed, 74% reported using CHG soap during their stay. Average compliance documented in the electronic medical record was 78% with a range of 57%‐91% among all hospital units. Sixteen percent of patients declined CHG bathing, and refusal ranged from 3%‐29% among all units. Major themes about CHG bathing from patient interviews include low perceived susceptibility to infection, high degree of trust in medical professionals, low knowledge of benefits of CHG, and low perceived self‐efficacy in preventing HAIs. Conclusions: Educating patients about CHG bathing appears to be a critical factor in decreasing patient refusal of CHG bathing.