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We assessed the implementation of telehealth-supported stewardship activities in acute-care units and long-term care (LTC) units in Veterans' Administration medical centers (VAMCs). Before-and-after, quasi-experimental implementation effectiveness study with a baseline period (2019-2020) and an intervention period (2021). The study was conducted in 3 VAMCs without onsite infectious disease (ID) support. The study included inpatient providers at participating sites who prescribe antibiotics. During 2021, an ID physician met virtually 3 times per week with the stewardship pharmacist at each participating VAMC to review patients on antibiotics in acute-care units and LTC units. Real-time feedback on prescribing antibiotics was given to providers. Additional implementation strategies included stakeholder engagement, education, and quality monitoring. The reach-effectiveness-adoption-implementation-maintenance (RE-AIM) framework was used for program evaluation. The primary outcome of effectiveness was antibiotic days of therapy (DOT) per 1,000 days present aggregated across all 3 sites. An interrupted time-series analysis was performed to compare this rate during the intervention and baseline periods. Electronic surveys, periodic reflections, and semistructured interviews were used to assess other RE-AIM outcomes. The telehealth program reviewed 502 unique patients and made 681 recommendations to 24 providers; 77% of recommendations were accepted. After program initiation, antibiotic DOT immediately decreased in the LTC units (-30%; < .01) without a significant immediate change in the acute-care units (+16%; = .22); thereafter DOT remained stable in both settings. Providers generally appreciated feedback and collaborative discussions. The implementation of our telehealth program was associated with reductions in antibiotic use in the LTC units but not in the smaller acute-care units. Overall, providers perceived the intervention as acceptable. Wider implementation of telehealth-supported stewardship activities may achieve reductions in antibiotic use.

Hospitals are required to have antibiotic stewardship programs (ASPs), but there are few models for implementing ASPs without the support of an infectious disease (ID) specialist, defined as an ID physician and/or ID pharmacist. In this study, we sought to understand ASP implementation at hospitals that lack on-site ID support within the Veterans' Health Administration (VHA). Using a mandatory VHA survey, we identified acute-care hospitals that lacked an on-site ID specialist. We conducted semistructured interviews with personnel involved in ASP activities. The study was conducted across 7 VHA hospitals. In total, 42 hospital personnel were enrolled in the study. The primary responsibility for ASPs fell on the pharmacist champions, who were typically assigned multiple other non-ASP responsibilities. The pharmacist champions were more successful at gaining buy-in when they had established rapport with clinicians, but at some sites, the use of contract physicians and frequent staff turnover were potential barriers. Some sites felt that having access to an off-site ID specialist was important for overcoming institutional barriers and improving the acceptance of their stewardship recommendations. In general, stewardship champions struggled to mobilize institutional resources, which made it difficult to advance their programmatic goals. In this study of 7 hospitals without on-site ID support, we found that ASPs are largely a pharmacy-driven process. Remote ID support, if available, was seen as helpful for implementing stewardship interventions. These findings may inform the future implementation of ASPs in settings lacking local ID expertise.

Background Ethnographic approaches offer a method and a way of thinking about implementation. This manuscript applies a specific case study method to describe the impact of the longitudinal interplay between implementation stakeholders. Growing out of science and technology studies (STS) and drawing on the latent archaeological sensibilities implied by ethnographic methods, the STS case-study is a tool for implementors to use when a piece of material culture is an essential component of an innovation. Methods We conducted an ethnographic process evaluation of the clinical implementation of tele-critical care (Tele-CC) services in the Department of Veterans Affairs. We collected fieldnotes and conducted participant observation at virtual and in-person education and planning events ( n  = 101 h). At Go-Live and 6-months post-implementation, we conducted site visits to the Tele-CC hub and 3 partnered ICUs. We led semi-structured interviews with ICU staff at Go-Live (43 interviews with 65 participants) and with ICU and Tele-CC staff 6-months post-implementation (44 interviews with 67 participants). We used verification strategies, including methodological coherence, appropriate sampling, collecting and analyzing data concurrently, and thinking theoretically, to ensure the reliability and validity of our data collection and analysis process. Results The STS case-study helped us realize that we must think differently about how a Tele-CC clinician could be noticed moving from communal to intimate space. To understand how perceptions of surveillance impacted staff acceptance, we mapped the materials through which surveillance came to matter in the stories staff told about cameras, buttons, chimes, motors, curtains, and doorbells. Conclusions STS case-studies contribute to the literature on longitudinal qualitive research (LQR) in implementation science, including pen portraits and periodic reflections. Anchored by the material, the heterogeneity of an STS case-study generates questions and encourages exploring differences. Begun early enough, the STS case-study method, like periodic reflections, can serve to iteratively inform data collection for researchers and implementors. The next step is to determine systematically how material culture can reveal implementation barriers and direct attention to potential solutions that address tacit, deeply rooted challenges to innovations in practice and technology.

Human papillomavirus (HPV) is the most prevalent sexually transmitted infection worldwide and can lead to the development of genital warts, and cancers throughout the body. Despite the availability of HPV vaccines for over a decade, uptake in the United States among adolescents and young adults remains well below national targets. While most efforts to improve HPV vaccine uptake have rightly focused on adolescents, there is still a tremendous opportunity to improve vaccination among young adults who have not been vaccinated against HPV. To that end, we report an exploratory examination of associations between HPV vaccination status and intentions with psychological traits that may impact HPV vaccine uptake with a national, demographically diverse sample of young adults (N = 1358) who completed an online survey. These psychological traits conceptually mapped onto motivations to: 1) understand health-related information, 2) deliberate, 3) manage uncertainty, and 4) manage threats. We found notable gender differences for the association of these motivations and vaccination status. For women, higher interest in and ability to understand health-related information seemed to distinguish those who reported receiving the HPV vaccine from those who did not. For men, less need to deliberate and greater needs to manage threat and uncertainty seemed to be the distinguishing motives for those who reported receiving the HPV vaccine compared to those who did not. Results for vaccination intentions were less consistent, but there was some evidence to indicate that, regardless of gender, greater health-related information interest and understanding and need to manage uncertainty and threats were associated with increased intention to receive the HPV vaccine, while greater need to deliberate was associated with decreased vaccination intentions. These results suggest that there are psychological differences that are associated with HPV vaccination decisions and that these motivations should be considered in efforts to improve HPV vaccine uptake.

To evaluate mortality, length of stay, and inter-hospital transfer in the Veteran Health Administration (VHA) among low complexity Intensive Care Unit (ICU) patients. Retrospective study of adult ICU admissions identified in VHA Medical SAS®; 2010–2015 at Veterans Affairs (VA) Medical Centers. Facilities classified by the Rural Urban Commuting Area code algorithm as large rural (referred to as rural) (N = 6) or urban (N = 33). In rural hospitals, patients (N = 9665) were less likely to have a respiratory (12.9% v. 18.9%; p < .001) diagnosis, more likely diagnosed with sepsis (17.6% v. 4.9%), and had a higher illness severity score (42.0 vs. 41.4; p = .01) compared to urban (N = 65,846) counterparts. Mortality within ICU did not vary across facility rurality. In unadjusted analyses, facility rurality (rural vs. urban) was associated with reduced inter-hospital transfers (OR = 0.74; 95% CI = [0.69, 0.80]; p < .001) and a shorter ICU length of stay (RR = 0.82; 95% CI = [0.74, 0.91]; p < .001). This did not hold when the hierarchical data was accounted for. Despite challenges, low complexity ICUs in rural VA facilities fare similarly to urban counterparts. Being part of a national healthcare system may have benefits to explore in sustaining critical care access in rural areas outside the VA healthcare system. •Patients at rural VA hospitals were less likely to have a respiratory diagnosis.•Mortality, length of stay, and transfers did not differ based on facility rurality.•Inter-hospital transfer more likely when patient had cardiovascular diagnosis.•Proper accounting of hierarchical data is necessary.

The Hawthorne Effect is a prevalent observer effect that causes behavioral changes among participants of epidemiological studies or infection control interventions. The purpose of the review is to describe the origins of the Hawthorne Effect, to understand the term in relation to current scientific literature, to describe characteristics of the Hawthorne effect, and to discuss methods to quantify and overcome limitations associated with the Hawthorne Effect. Infect. Control Hosp. Epidemiol. 2015;36(12):1444–1450

Hand hygiene compliance decreased significantly when opportunities exceeded 30 per hour. At higher workloads, the number of healthcare worker types involved and the proportion of hand hygiene opportunities for which physicians and other healthcare workers were responsible increased. Thus, care complexity and risk to patients may both increase with workload.

Background An application-oriented implementation framework designed for clinicians and based on the Diffusion of Innovations theory included 81 implementation strategies with suggested timing for use within four implementation phases. The purpose of this research was to evaluate and strengthen the framework for clinician use and propose its usefulness in implementation research. Methods A multi-step, iterative approach guided framework revisions. Individuals requesting the use of the framework over the previous 7 years were sent an electronic questionnaire. Evaluation captured framework usability, generalizability, accuracy, and implementation phases for each strategy. Next, nurse leaders who use the framework pile sorted strategies for cultural domain analysis. Last, a panel of five EBP/implementation experts used these data and built consensus to strengthen the framework. Results Participants ( n = 127/1578; 8% response) were predominately nurses (94%), highly educated (94% Master’s or higher), and from across healthcare (52% hospital/system, 31% academia, and 7% community) in the USA (84%). Most (96%) reported at least some experience using the framework and 88% would use the framework again. A 4-point scale (1 = not/disagree to 4 = very/agree) was used. The framework was deemed useful (92%, rating 3–4), easy to use (72%), intuitive (67%), generalizable (100%), flexible and adaptive (100%), with accurate phases (96%), and accurate targets (100%). Participants ( n = 51) identified implementation strategy timing within four phases (Cochran’s Q ); 54 of 81 strategies (66.7%, p < 0.05) were significantly linked to a specific phase; of these, 30 (55.6%) matched the original framework. Next, nurse leaders ( n = 23) completed a pile sorting activity. Anthropac software was used to analyze the data and visualize it as a domain map and hierarchical clusters with 10 domains. Lastly, experts used these data and implementation science to refine and specify each of the 75 strategies, identifying phase, domain, actors, and function. Strategy usability, timing, and groupings were used to refine the framework. Conclusion The Iowa Implementation for Sustainability Framework offers a typology to guide implementation for evidence-based healthcare. This study specifies 75 implementation strategies within four phases and 10 domains and begins to validate the framework. Standard use of strategy names is foundational to compare and understand when implementation strategies are effective, in what dose, for which topics, by whom, and in what context.

Comparison of Quality Improvement and Implementation Science Element Quality Improvement Implementation Science Focus Context dependent (ie, fix a specific problem on a local level) Broad (ie, underutilization of an evidence-based practice across healthcare) Goal To fix a specific problem within a single healthcare system To generate generalizable knowledge on mechanisms of change that can be applied to different locations Approach Design and test strategies to address the problem Evaluation Qualitative and quantitative methods to measure processes, outcomes, and barriers/facilitators to change Models or frameworks Toyota lean Six sigma Process (eg, Pronovost) Determinant (eg, CFIR) Evaluation (eg, RE-AIM) Here, we take the reader through the steps involved in the design and conduct of an implementation research study, while introducing and defining key implementation science principles. [...]we describe how to evaluate the implementation process. Implementation science focuses on generating knowledge about how to improve health outcomes by reducing the gap between what we know works to promote health (ie, an evidence-based practice) and how we actually make it work (ie, how we deliver evidence-based practice in routine, real-world settings).7,8 Therefore, it is critical to establish whether your project addresses a gap between evidence-based optimal practice and the current status quo.9 Establishing that such an evidence gap exists requires data from either the local setting or from the extant research literature.10 Identifying this gap in antibiotic stewardship should begin with documenting whether antibiotic prescribing in a clinical setting is consistent with the best available evidence. Implementation Strategies Category of Implementation Strategy Specific Strategies Within the Category Evaluative and iterative strategies Audit and provide feedbacka Assess readiness for change Conduct cyclical small tests of change Develop stakeholder relationships Identify and prepare champions Identify early adopters Obtain commitment letters Capture and share local knowledgeb Build a coalition Conduct local consensus discussionsc Train and educate stakeholders Conduct ongoing training Develop and distribute educational materials Support clinicians Clinician promptsd Facilitate relay of clinical data to clinicianse Change infrastructure Mandate changef Change accreditation requirements Adapt and tailor to the context Tailor strategies Promote adaptability Provide interactive assistance Facilitation Centralize technical assistanceg Engage consumers Involve patients and family membersh Prepare patients to be active participantsi Use mass media Utilize financial strategies Alter incentive structures for clinicians In simplistic terms, the evidence-based practice is “the thing” that is known to be effective in improving health or minimizing harm, based on prior studies.17 The implementation strategy is what is done “to try to help people and places ‘do the thing.’”

Surgical-site infections (SSIs) can be catastrophic. Bundles of evidence-based practices can reduce SSIs but can be difficult to implement and sustain. We sought to understand the implementation of SSI prevention bundles in 6 US hospitals. Qualitative study. We conducted in-depth semistructured interviews with personnel involved in bundle implementation and conducted a thematic analysis of the transcripts. The study was conducted in 6 US hospitals: 2 academic tertiary-care hospitals, 3 academic-affiliated community hospitals, 1 unaffiliated community hospital. In total, 30 hospital personnel participated. Participants included surgeons, laboratory directors, clinical personnel, and infection preventionists. Bundle complexity impeded implementation. Other barriers varied across services, even within the same hospital. Multiple strategies were needed, and successful strategies in one service did not always apply in other areas. However, early and sustained interprofessional collaboration facilitated implementation. The evidence-based SSI bundle is complicated and can be difficult to implement. One implementation process probably will not work for all settings. Multiple strategies were needed to overcome contextual and implementation barriers that varied by setting and implementation climate. Appropriate adaptations for specific settings and populations may improve bundle adoption, fidelity, acceptability, and sustainability.