Decision-making regarding antibiotic therapy duration: An observational study of multidisciplinary meetings in the intensive care unit

PURPOSE

Antibiotic therapy is commonly prescribed longer than recommended in intensive care patients (ICU). We aimed to provide insight into the decision-making process on antibiotic therapy duration in the ICU.

METHODS

A qualitative study was conducted, involving direct observations of antibiotic decision-making during multidisciplinary meetings in four Dutch ICUs. The study used an observation guide, audio recordings, and detailed field notes to gather information about the discussions on antibiotic therapy duration. We described the participants' roles in the decision-making process and focused on arguments contributing to decision-making.

RESULTS

We observed 121 discussions on antibiotic therapy duration in sixty multidisciplinary meetings. 24.8% of discussions led to a decision to stop antibiotics immediately. In 37.2%, a prospective stop date was determined. Arguments for decisions were most often brought forward by intensivists (35.5%) and clinical microbiologists (22.3%). In 28.9% of discussions, multiple healthcare professionals participated equally in the decision. We identified 13 main argument categories. While intensivists mostly used arguments based on clinical status, clinical microbiologists used diagnostic results in the discussion.

CONCLUSIONS

Multidisciplinary decision-making regarding the duration of antibiotic therapy is a complex but valuable process, involving different healthcare professionals, using a variety of argument-types to determine the duration of antibiotic therapy. To optimize the decision-making process, structured discussions, involvement of relevant specialties, and clear communication and documentation of the antibiotic plan are recommended.

Considerable doubt about rubella screening and vaccination among unvaccinated orthodox protestant women: a mixed-methods study

BACKGROUND

Women who are susceptible to rubella are advised to vaccinate against rubella to prevent infection in future pregnancies, and thus avert the risk of congenital rubella syndrome in their unborn child. Rubella outbreaks periodically occur in the under-vaccinated orthodox Protestant community in the Netherlands. The objective of this mixed-methods study was to determine and understand personal experience with rubella, perceived rubella susceptibility, and intention to accept rubella screening and vaccination among unvaccinated orthodox Protestant women. The ultimate aim of this study was to inform policy and practice and contribute to the prevention of cases of congenital rubella syndrome.

METHODS

A mixed-methods study was conducted combining an online survey and semi-structured interviews among unvaccinated Dutch orthodox Protestant women aged 18-40 years. Descriptive analysis was used for quantitative data. Qualitative data was analysed using codes and categories.

RESULTS

Results of the survey (167 participants) showed that most participants had personal experience with rubella (74%, 123/167) and 101 women (61%, 101/167) indicated they had had rubella themselves. More than half of the women were undecided whether to accept rubella susceptibility screening (56%; 87/156) or rubella vaccination (55%; 80/146). Qualitative findings (10 participants) showed that most women thought they were not susceptible to rubella. Indecisiveness and negative attitudes to accept rubella vaccination were related with religious arguments to object vaccination and with women's perception of absence of imminent threat of rubella. Furthermore, results showed presence of misconceptions among women in the interpretation of their susceptibility and high confidence in their parents' memory that they had experienced rubella as a child although no laboratory screening had been conducted.

CONCLUSIONS

In light of an imminent rubella outbreak in the Netherlands, a tailored education campaign should be prepared aimed at and established in cooperation with the under-vaccinated orthodox Protestant community. Health care providers should provide adequate information on rubella and support decision-making in order to stimulate women to make a deliberate and informed decision on rubella screening and, if necessary, subsequent vaccination.

How to use quality indicators for antimicrobial stewardship in your hospital: a practical example on outpatient parenteral antimicrobial therapy

BACKGROUND

Antimicrobial stewardship (AMS) teams are responsible for performing an AMS programme in their hospitals that aims to improve the quality of antibiotic use. Measuring the quality of antimicrobial use is a core task of a stewardship team. Measurement provides insight into the current quality of antibiotic use and allows for the establishment of goals for improvement. Yet, a practical description of how such a quality measurement using quality indicators (QIs) should be performed is lacking.

OBJECTIVES

To provide practical guidance on how a stewardship team can use QIs to measure the quality of antibiotic use in their hospital and identify targets for improvement.

SOURCES

General principles from implementation science, peer-reviewed publications, and experience from clinicians and researchers with AMS experience.

CONTENT

We provide step-by-step guidance on how AMS teams can use QIs to measure the quality of antibiotic use. The principles behind each step are explained and illustrated with the description and results of an audit of patients receiving outpatient parenteral antimicrobial therapy in four Dutch hospitals.

IMPLICATIONS

Improving the quality of antibiotic use is impossible without first gaining insight into that quality by performing a measurement with validated QIs. This step-by-step practice example of how to use quality indicators in a hospital will help AMS teams to identify targets for improvement. This enables them to perform their AMS programme more effectively and efficiently.

A systematic literature review to clarify the concept of vaccine hesitancy

Vaccine hesitancy (VH) is considered a top-10 global health threat. The concept of VH has been described and applied inconsistently. This systematic review aims to clarify VH by analysing how it is operationalized. We searched PubMed, Embase and PsycINFO databases on 14 January 2022. We selected 422 studies containing operationalizations of VH for inclusion. One limitation is that studies of lower quality were not excluded. Our qualitative analysis reveals that VH is conceptualized as involving (1) cognitions or affect, (2) behaviour and (3) decision making. A wide variety of methods have been used to measure VH. Our findings indicate the varied and confusing use of the term VH, leading to an impracticable concept. We propose that VH should be defined as a state of indecisiveness regarding a vaccination decision.

Current Practices and Opportunities for Outpatient Parenteral Antimicrobial Therapy in Hospitals: A National Cross-Sectional Survey

This nationwide study assessed how outpatient parenteral antimicrobial therapy (OPAT) is organised by Dutch acute care hospitals, the barriers experienced, and how an OPAT program affects the way hospitals organised OPAT care. We systematically developed and administered a survey to all 71 Dutch acute care hospitals between November 2021 and February 2022. Analyses were primarily descriptive and included a comparison between hospitals with and without an OPAT program. Sixty of the 71 hospitals (84.5%) responded. Fifty-five (91.7%) performed OPAT, with a median number of 20.8 (interquartile range [IQR] 10.3-29.7) patients per 100 hospital beds per year. Of these 55 hospitals, 31 (56.4%) had selection criteria for OPAT and 34 (61.8%) had a protocol for laboratory follow-up. Sixteen hospitals (29.1%) offered self-administered OPAT (S-OPAT), with a median percentage of 5.0% of patients (IQR: 2.3%-10.0%) actually performing self-administration. Twenty-five hospitals (45.5%) had an OPAT-related outcome registration. The presence of an OPAT program (22 hospitals, 40.0%) was significantly associated with aspects of well-organised OPAT care. The most commonly experienced barriers to OPAT implementation were a lack of financial, administrative, and IT support and insufficient time of healthcare staff. Concluding, hospital-initiated OPAT is widely available in the Netherlands, but various aspects of well-organised OPAT care can be improved. Implementation of a team-based OPAT program can contribute to such improvements. The observed variation provides leads for further scientific research, guidelines, and practical implementation programs.

OUP accepted manuscript

Background

In daily hospital practice, antibiotic therapy is commonly prescribed for longer than recommended in guidelines. Understanding the key drivers of prescribing behaviour is crucial to generate meaningful interventions to bridge this evidence-to-practice gap.

Objectives

To identify behavioural determinants that might prevent or enable improvements in duration of antibiotic therapy in daily practice.

Methods

We systematically searched PubMed, Embase, PsycINFO and Web of Science for relevant studies that were published between January 2000 and August 2021. All qualitative, quantitative and mixed-method studies in adults in a hospital setting that reported determinants of antibiotic therapy duration were included.

Results

Twenty-two papers were included in this review. A first set of studies provided 82 behavioural determinants that shape how health professionals make decisions about duration; most of these were related to individual health professionals’ knowledge, skills and cognitions, and to professionals’ interactions. A second set of studies provided 17 determinants that point to differences in duration regarding various pathogens, diseases, or patient, professional or hospital department characteristics, but do not explain why or how these differences occur.

Conclusions

Limited literature is available describing a wide range of determinants that influence duration of antibiotic therapy in daily practice. This review provides a stepping stone for the development of stewardship interventions to optimize antibiotic therapy duration, but more research is warranted. Stewardship teams must develop complex improvement interventions to address the wide variety of behavioural determinants, adapted to the specific pathogen, disease, patient, professional and/or hospital department involved.

Acceptability of innovative culture-based antibiotic prophylaxis strategies: a multi-method study on experiences regarding transrectal prostate biopsy

Background

The acceptability of innovative medical strategies among healthcare providers and patients affects their uptake in daily clinical practice.

Objectives

To explore experiences of healthcare providers and patients with culture-based antibiotic prophylaxis in transrectal prostate biopsy with three swab-screening scenarios: self-sampling at home, self-sampling in the hospital and sampling by a healthcare provider.

Methods

We performed focus group interviews with urologists and medical microbiologists from 11 hospitals and six connected clinical microbiological laboratories. We used Flottorp's comprehensive checklist for identifying determinants of practice to guide data collection and analysis. The experiences of 10 laboratory technicians from five laboratories and 452 patients from nine hospitals were assessed using a questionnaire.

Results

Overall, culture-based prophylaxis strategies were experienced as feasible in daily clinical practice. None of the three swab-screening scenarios performed better. For urologists (n = 5), implementation depended on the effectiveness of the strategy. In addition, it was important to them that the speed of existing oncology care pathways is preserved. Medical microbiologists (n = 5) and laboratory technicians (n = 8) expected the strategy to be fairly easy to implement. Patients (n = 430; response rate 95.1%) were generally satisfied with the screening scenario presented to them. To meet the various patients' needs and preferences, multiple scenarios within a hospital are probably needed.

Conclusions

This multi-method study has increased our understanding of the acceptability of culture-based prophylaxis strategies in prostate biopsy, which can help healthcare providers to offer high-quality patient-centred care. The strategy seems relatively straightforward to implement as overall acceptance appears to be high.

Tricyclic antidepressants for major depressive disorder: a comprehensive evaluation of current practice in the Netherlands

BACKGROUND

Traditionally tricyclic antidepressants (TCAs) have an important place in treatment of major depressive disorder (MDD). Today, often other antidepressant medications are considered as first step in the pharmacological treatment of MDD, mainly because they are associated with less adverse effects, whereby the position of TCAs appears unclear. In this study we aimed to examine the current practice of TCAs in treatment of unipolar MDD.

METHODS

A mixed methods approach was applied. First, a selection of leading international and national guidelines was reviewed. Second, actual TCA prescription was examined by analyzing health records of 75 MDD patients treated with the TCAs nortriptyline, clomipramine or imipramine in different centers in the Netherlands. Third, promotors and barriers influencing the choice for TCAs and dosing strategies were explored using semi-structured interviews with 24 Dutch psychiatrists.

RESULTS

Clinical practice guidelines were sometimes indirective and inconsistent with each other. Health records revealed that most patients (71%) attained therapeutic plasma concentrations within two months of TCA use. Patients who achieved therapeutic plasma concentrations reached them on average after 19.6 days (SD 10.9). Both health records and interviews indicated that therapeutic nortriptyline concentrations were attained faster compared to other TCAs. Various factors were identified influencing the choice for TCAs and dosing by psychiatrists.

CONCLUSIONS

Guideline recommendations and clinical practice regarding TCA prescription for MDD vary. To increase consistency in clinical practice we recommend development of an up-to-date guideline integrating selection and dosing of TCAs, including the roles of therapeutic drug monitoring and pharmacogenetics. Such a guideline is currently lacking and would contribute to optimal TCA treatment, whereby efficacy and tolerability may be increased.

A multicentre cluster-randomized clinical trial to improve antibiotic use and reduce length of stay in hospitals: comparison of three measurement and feedback methods

BACKGROUND

Various metrics of hospital antibiotic use might assist in guiding antimicrobial stewardship (AMS).

OBJECTIVES

To compare patient outcomes in association with three methods to measure and feedback information on hospital antibiotic use when used in developing an AMS intervention.

METHODS

Three methods were randomly allocated to 42 clusters from 21 Dutch hospitals: (1) feedback on quantity of antibiotic use [DDD, days-of-therapy (DOT) from hospital pharmacy data], versus feedback on (2) validated, or (3) non-validated quality indicators from point prevalence studies. Using this feedback together with an implementation tool, stewardship teams systematically developed and performed improvement strategies. The hospital length of stay (LOS) was the primary outcome and secondary outcomes included DOT, ICU stay and hospital mortality. Data were collected before (February-May 2015) and after (February-May 2017) the intervention period.

RESULTS

The geometric mean hospital LOS decreased from 9.5 days (95% CI 8.9-10.1, 4245 patients) at baseline to 9.0 days (95% CI 8.5-9.6, 4195 patients) after intervention (P < 0.001). No differences in effect on LOS or secondary outcomes were found between methods. Feedback on quality of antibiotic use was used more often to identify improvement targets and was preferred over feedback on quantity of use. Consistent use of the implementation tool seemed to increase effectiveness of the AMS intervention.

CONCLUSIONS

The decrease in LOS versus baseline likely reflects improvement in the quality of antibiotic use with the stewardship intervention. While the outcomes with the three methods were otherwise similar, stewardship teams preferred data on the quality over the quantity of antibiotic use.

Quantity Metrics and Proxy Indicators to Estimate the Volume and Appropriateness of Antibiotics Prescribed in French Nursing Homes: A Cross-sectional Observational Study Based on 2018 Reimbursement Data

BACKGROUND

Antibiotic resistance is an increasing threat to public health globally. Indicators on antibiotic prescribing are required to guide antibiotic stewardship interventions in nursing homes. However, such indicators are not available in the literature. Our main objective was to provide a set of quantity metrics and proxy indicators to estimate the volume and appropriateness of antibiotic use in nursing homes.

METHODS

Recently published articles were first used to select quantity metrics and proxy indicators, which were adapted to the French nursing home context. A cross-sectional observational study was then conducted based on reimbursement databases. We included all community-based nursing homes of the Lorraine region in northeastern France. We present descriptive statistics for quantity metrics and proxy indicators. For proxy indicators, we also assessed performance scores, clinimetric properties (measurability, applicability, and room for improvement), and conducted case-mix and cluster analyses.

RESULTS

A total of 209 nursing homes were included. We selected 15 quantity metrics and 11 proxy indicators of antibiotic use. The volume of antibiotic use varied greatly between nursing homes. Proxy indicator performance scores were low, and variability between nursing homes was high for all indicators, highlighting important room for improvement. Six of the 11 proxy indicators had good clinimetric properties. Three distinct clusters were identified according to the number of proxy indicators for which the acceptable target was reached.

CONCLUSIONS

This set of 15 quantity metrics and 11 proxy indicators may be adapted to other contexts and could be used to guide antibiotic stewardship programs in nursing homes.

Co-Design of a Disease Activity Based Self-Management Approach for Patients with Rheumatoid Arthritis

Objective:

The systematic development of an intervention to improve disease activity-based management of rheumatoid arthritis (RA) in daily clinical practice that is based on patient-level barriers.

Methods:

The self-management strategy was developed through a step-wise approach, in a process of co-design with all stakeholders and by addressing patient level barriers to RA management based on disease activity.

Results:

The resulting DAS-pass strategy consists of decision supportive information and guidance by a specialised rheumatology nurse. It aims to increase patients’ knowledge on DAS28, to empower patients to be involved in disease management, and to improve patients’ medication beliefs. The decision supportive information includes an informational leaflet and a patient held record. The nurse individualises the information, stimulates patients to communicate about disease activity, and offers the opportunity for questions or additional support.

Conclusion:

The DAS-pass strategy was found helpful by stakeholders. It can be used to improve RA daily clinical practice. Our systematic approach can be used to improve patient knowledge and self-management on other RA related topics. Also, it can be used to improve the management of other chronic conditions. We therefore provide a detailed description of our methodology to assist those interested in developing an evidence-based strategy for educating and empowering patients.

Decision-making on maternal pertussis vaccination among women in a vaccine-hesitant religious group: Stages and needs

Introduction

As of December 2019, pregnant women in the Netherlands are offered pertussis vaccination to protect their newborn infant against pertussis infection. However, the manner in which pregnant women decide about this maternal pertussis vaccination is largely unknown. The aim of this study is to gain insight into the decision-making process regarding maternal pertussis vaccination, and to explore the related needs among the vaccine-hesitant subgroup of orthodox Protestant women.

Methods

Charmaz’s grounded theory approach was used to develop a decision-making framework. To construct this framework we used an explorative multimethod approach in which in-depth interviews and online focus groups were supplemented by a literature search and research group meetings. This study was carried out in a hypothetical situation since the maternal pertussis vaccination had yet to be implemented in the Dutch immunisation programme at the time of the study.

Results

Twenty-five orthodox Protestant women participated in an interview, an online focus group, or in both. The findings of this study resulted in a decision-making framework that included three stages of decision-making; an Orientation stage, a value-based Deliberation stage, and Final decision stage. The Orientation stage included the needs for decision-making categorised into Information needs and Conversation needs. Women indicated that -if they were to receive sufficient time for Orientation and Deliberation- they would be able to reach the stage of Final decision.

Conclusion

The decision-making framework resulting from our findings can be used by health care professionals to provide women with information and consultation in the decision-making process. Future studies should investigate whether the stages of and needs for decision-making can be found across other vaccine-hesitant subgroups and vaccinations.

Proxy indicators to estimate the appropriateness of medications prescribed by paediatricians in infectious diseases: a cross-sectional observational study based on reimbursement data

Background

We previously developed proxy indicators (PIs) that can be used to estimate the appropriateness of medications used for infectious diseases (in particular antibiotics) in primary care, based on routine reimbursement data that do not include clinical indications.

Objectives

To: (i) select the PIs that are relevant for children and estimate current appropriateness of medications used for infectious diseases by French paediatricians and its variability while using these PIs; (ii) assess the clinimetric properties of these PIs using a large regional reimbursement database; and (iii) compare performance scores for each PI between paediatricians and GPs in the paediatric population.

Methods

For all individuals living in north-eastern France, a cross-sectional observational study was performed analysing National Health Insurance data (available at prescriber and patient levels) regarding antibiotics prescribed by their paediatricians in 2017. We measured performance scores of the PIs, and we tested their clinimetric properties, i.e. measurability, applicability and room for improvement.

Results

We included 116 paediatricians who prescribed a total of 44 146 antibiotic treatments in 2017. For all four selected PIs (seasonal variation of total antibiotic use, amoxicillin/second-line antibiotics ratio, co-prescription of anti-inflammatory drugs and antibiotics), we found large variations between paediatricians. Regarding clinimetric properties, all PIs were measurable and applicable, and showed high improvement potential. Performance scores did not differ between these 116 paediatricians and 3087 GPs.

Conclusions

This set of four proxy indicators might be used to estimate appropriateness of prescribing in children in an automated way within antibiotic stewardship programmes.

Development of quality indicators for the management of Staphylococcus aureus bacteraemia

Background

Staphylococcus aureus bacteraemia (SAB) is a serious and often fatal infectious disease. The quality of management of SAB is modifiable and can thus affect the outcome. Quality indicators (QIs) can be used to measure the quality of care of the various aspects of SAB management in hospitals, enabling professionals to identify targets for improvement and stimulating them to take action.

Objectives

To develop QIs for the management of hospitalized patients with SAB.

Methods

A RAND-modified Delphi procedure was used to develop a set of QIs for the management of SAB in hospitalized patients. First, available QIs for the management of SAB were extracted from the literature published since 1 January 2000 (MEDLINE and Embase databases). Thereafter, an international multidisciplinary expert panel appraised these QIs during two questionnaire rounds with an intervening face-to-face meeting.

Results

The literature search resulted in a list of 39 potential QIs. After appraisal by 30 medical specialists, 25 QIs describing recommended care at patient level were selected. These QIs defined appropriate follow-up blood cultures (n=2), echocardiography (n=6), source control (n=4), antibiotic therapy (n=7), antibiotic dose adjustment (n=2), intravenous-to-oral switch (n=2), infectious disease consultation (n=1) and medical discharge report (n=1).

Conclusions

A set of 25 QIs for the management of SAB for hospitalized patients was developed by using a RAND-modified Delphi procedure among international experts. These QIs can measure the quality of various aspects of SAB management. This information can be fed back to the relevant stakeholders in order to identify improvement targets and optimize care.

Hand hygiene compliance in Dutch general practice offices

BACKGROUND

Hand hygiene (HH) is considered one of the most important measures to prevent healthcare-associated infections (HAI). Most studies focus on HH compliance within the hospital setting, whereas little is known for the outpatient setting. The aim of this study was to evaluate compliance with HH recommendations in general practitioners (GPs) office, based on World Health Organization (WHO) guideline.

METHODS

An observational study was conducted at five Dutch GPs-practices in September 2017. We measured HH compliance through direct observation using WHO's 'five moments of hand hygiene' observation tool. All observations were done by one trained professional.

RESULTS

We monitored a total of 285 HH opportunities for 30 health care workers (HCWs). The overall compliance was 37%. Hand hygiene compliance was 34, 51 and 16% for general practitioners, practice assistants, and nurses, respectively. It varies between 63% after body fluid exposure and no HH performance before-, during and after home visit of a patient (defined as moment 5). The preferred method of HH was soap and water (63%) versus 37% for alcohol-based hand rub (ABHR). The median time of disinfecting hands was 8 s (range 6-11 s) for HCWs in our study.

CONCLUSIONS

HH compliance among HCWs in Dutch GPs was found to be low, especially with regard to home visits. The WHO recommended switch from hand wash to ABHR was not implemented by the majority of HCWs in 5 observed GPs offices.

Two parallel short forms to measure disease- and treatment-associated knowledge in rheumatoid arthritis: application of item response theory

Objective

The aim was to develop two disease- and treatment-related knowledge about RA (DataK-RA) short forms using item response theory-based linear optimal test design.

Methods

We used the open source Excel add-in solver to program a linear optimization algorithm to develop two short forms from the DataK-RA item bank. The algorithm was instructed to optimize precision (i.e. reliability) of the scores for both short forms, subject to a number of constraints that served to ensure that each short form would include unique items and that the short forms would have similar psychometric properties. Agreement among item response theory scores obtained from the different short forms was assessed using the Bland–Altman method and Student’s paired t-test. Construct validity and relative efficiency of the short forms was evaluated by relating the score to age, sex and educational attainment.

Results

Two short forms were derived from the DataK-RA item bank that satisfied all content constraints. Both short forms included 15 unique items and yielded reliable scores (r &gt; 0.70), with low ceiling and floor effects. The short forms yielded statistically indistinguishable mean scores according to Student’s paired t-test and Bland–Altman analysis. Scores on short forms 1 and 2 were associated with age, sex and educational attainment to a similar extent.

Conclusion

In this study, we developed two DataK-RA short forms with unique items, yet similar psychometric properties, that can be used to assess patients pre- and post-test interventions aimed at improving disease-related knowledge in RA patients.

Prostate biopsy techniques and pre-biopsy prophylactic measures: variation in current practice patterns in the Netherlands

BACKGROUND

The clinical landscape of prostate biopsy (PB) is evolving with changes in procedures and techniques. Moreover, antibiotic resistance is increasing and influences the efficacy of pre-biopsy prophylactic regimens. Therefore, increasing antibiotic resistance may impact on clinical care, which probably results in differences between hospitals. The objective of our study is to determine the (variability in) current practices of PB in the Netherlands and to gain insight into Dutch urologists' perceptions of fluoroquinolone resistance and biopsy related infections.

METHODS

An online questionnaire was prepared using SurveyMonkey® platform and distributed to all 420 members of the Dutch Association of Urology, who work in 81 Dutch hospitals. Information about PB techniques and periprocedural antimicrobial prophylaxis was collected. Urologists' perceptions regarding pre-biopsy antibiotic prophylaxis in an era of antibiotic resistance was assessed. Descriptive statistical analysis was performed.

RESULTS

One hundred sixty-one responses (38.3%) were analyzed representing 65 (80.3%) of all Dutch hospitals performing PB. Transrectal ultrasound guided prostate biopsy (TRUSPB) was performed in 64 (98.5%) hospitals. 43.1% of the hospitals (also) used other image-guided biopsy techniques. Twenty-three different empirical prophylactic regimens were reported among the hospitals. Ciprofloxacin was most commonly prescribed (84.4%). The duration ranged from one pre-biopsy dose (59.4%) to 5 days extended prophylaxis. 25.2% of the urologists experienced ciprofloxacin resistance as a current problem in the prevention of biopsy related infections and 73.6% as a future problem.

CONCLUSIONS

There is a wide variation in practice patterns among Dutch urologists. TRUSPB is the most commonly used biopsy technique, but other image-guided biopsy techniques are increasingly used. Antimicrobial prophylaxis is not standardized and prolonged prophylaxis is common. The wide variation in practice patterns and lack of standardization underlines the need for evidence-based recommendations to guide urologists in choosing appropriate antimicrobial prophylaxis for PB in the context of increasing antibiotic resistance.

[Ethically responsible care for MDRO carriers]

Dutch healthcare institutions are relatively successful in preventing outbreaks of antibiotic-resistant pathogens, thus protecting vulnerable patients. However, measures taken to prevent the introduction and spread of MDROs can be burdensome for asymptomatic carriers of such bacteria or for people who may have been exposed to them. This leads to ethical dilemmas. On the basis of a study of the impact of being a carrier and precautionary measures on carrier well-being, we present an ethical framework for responsible care for carriers. We argue that solidarity requires that the burden of prevention and control of resistance is to be shouldered by society as a whole. It is not right to see this problem primarily as a conflict between the protection of vulnerable patients on the one hand and carriers on the other.

Implementation and evaluation of an antimicrobial stewardship programme in companion animal clinics: A stepped-wedge design intervention study

BACKGROUND

To curb increasing resistance rates, responsible antimicrobial use (AMU) is needed, both in human and veterinary medicine. In human healthcare, antimicrobial stewardship programmes (ASPs) have been implemented worldwide to improve appropriate AMU. No ASPs have been developed for and implemented in companion animal clinics yet.

OBJECTIVES

The objective of the present study was to implement and evaluate the effectiveness of an ASP in 44 Dutch companion animal clinics. The objectives of the ASP were to increase awareness on AMU, to decrease total AMU whenever possible and to shift AMU towards 1st choice antimicrobials, according to Dutch guidelines on veterinary AMU.

METHODS

The study was designed as a prospective, stepped-wedge, intervention study, which was performed from March 2016 until March 2018. The multifaceted intervention was developed using previous qualitative and quantitative research on current prescribing behaviour in Dutch companion animal clinics. The number of Defined Daily Doses for Animal (DDDAs) per clinic (total, 1st, 2nd and 3rd choice AMU) was used to quantify systemic AMU. Monthly AMU data were described using a mixed effect time series model with auto-regression. The effect of the ASP was modelled using a step function and a change in the (linear) time trend.

RESULTS

A statistically significant decrease of 15% (7%-22%) in total AMU, 15% (5%-24%) in 1st choice AMU and 26% (17%-34%) in 2nd choice AMU was attributed to participation in the ASP, on top of the already ongoing time trends. Use of 3rd choice AMs did not significantly decrease by participation in the ASP. The change in total AMU became more prominent over time, with a 16% (4%-26%) decrease in (linear) time trend per year.

CONCLUSIONS

This study shows that, although AMU in Dutch companion animal clinics was already decreasing and changing, AMU could be further optimised by participation in an antimicrobial stewardship programme.

A survey on antimicrobial stewardship prerequisites, objectives and improvement strategies: systematic development and nationwide assessment in Dutch acute care hospitals

Background

Stewardship guidelines define three essential building blocks for successful hospital antimicrobial stewardship programmes (ASPs): stewardship prerequisites, stewardship objectives and improvement strategies.

Objectives

We systematically developed a survey, based on these building blocks, to evaluate the current state of antimicrobial stewardship in hospitals. We tested this survey in 64 Dutch acute care hospitals.

Methods

We performed a literature review on surveys of antimicrobial stewardship. After extraction and categorization of survey questions, five experts merged and rephrased questions during a consensus meeting. After a pilot study, the survey was sent to 80 Dutch hospitals.

Results

The final survey consisted of 46 questions, categorized into hospital characteristics, stewardship prerequisites, stewardship objectives and stewardship strategies. The response rate was 80% (n = 64). Ninety-four percent of hospitals had established an antimicrobial stewardship team, consisting of at least one hospital pharmacist and one clinical microbiologist. An infectious diseases specialist was present in 68% of the teams. Nine percent had dedicated IT support. Forty-one percent of the teams were financially supported, with a median of 0.6 full-time equivalents (FTE; 0.1-1.8). The majority of hospitals performed monitoring of restricted antibiotic agents (91%), dose optimization (65%), bedside consultation (56%) and intravenous-to-oral switch (53%). Fifty-eight percent of the hospitals provided education to residents and 28% to specialists.

Conclusions

The survey provides information on the progress that is being made in hospitals regarding the three building blocks of a successful ASP, and provides clear aims to strengthen ASPs. Ultimately, these data will be related to national data on antibiotic consumption and resistance.

Comparison of antimicrobial stewardship programmes in acute-care hospitals in four European countries: A cross-sectional survey

Antimicrobial stewardship programmes (ASPs) are designed to improve antibiotic use. A survey was systematically developed to assess ASP prerequisites, objectives and improvement strategies in hospitals. This study assessed the current state of ASPs in acute-care hospitals throughout Europe. A survey containing 46 questions was disseminated to acute-care hospitals: all Dutch (n = 80) and Slovenian (n = 29), 215 French (25%, random stratified sampling) and 62 Italian (49% of hospitals with an infectious diseases department, convenience sampling) acute-care hospitals, for a Europe-wide assessment. Response rates for the Netherlands (Nl), Slovenia (Slo), France (Fr) and Italy (It) were 80%, 86%, 45% and 66%. There was variation between countries in the prerequisites met and the objectives and improvement strategies chosen. A formal ASP was present mainly in the Netherlands (90%) and France (84%) compared with Slovenia (60%) and Italy (60%). Presence of an antimicrobial stewardship (AMS) team ranged from 42% (Fr) to 94% (Nl). Salary support for AMS teams was provided in 68% (Fr), 51% (Nl), 33% (Slo) and 12% (It) of surveyed hospitals. Quantity of antibiotic use was monitored in the majority of hospitals, ranging from 72% (Nl) to 100% (Slo and Fr) of acute-care hospitals. Participating countries varied substantially in the use of 'prospective monitoring and advice' as a strategy to improve AMS objectives. ASP prerequisites, objectives and improvement activities vary considerably across Europe, with room for improvement. Stimulating appropriate system prerequisites throughout Europe, e.g. by introducing staffing standards and financial support for ASPs, seems a first priority.

Current practice of infection control in Dutch primary care: Results of an online survey

BACKGROUND

Good infection prevention is an important aspect of quality of medical care. The aim was to evaluate infection prevention and control (IPC) performance among Dutch general practitioners (GPs).

METHODS

Based on the current national IPC guidelines for GPs, a self-administered anonymous online questionnaire was developed and sent to GPs in the Nijmegen region of the Netherlands. Thirty-two questions were constructed to survey characteristics of GPs' offices and assess current performance of IPC measures.

RESULTS

One hundred questionnaires were included in our analysis. The preferred method of hand hygiene was soap and water (56%) versus alcohol-based handrub (44%). The cleaning of nondisposable, noncritical, semicritical, and critical instruments was consistent with national guideline recommendations or superior to them in 100%, 49%, and 97% of cases, respectively. An average of 57% of GPs reported environmental cleaning frequencies that were compliant with the national guidelines or superior to them. Personal protective equipment was available in 62% of GPs' practices but used in only 25% of home visits to patients.

CONCLUSIONS

Not all national IPC guidelines seem to be followed to the fullest extent. The current situation indicates there is room for potential improvement regarding implementation of IPC measures in GPs' offices. Area-specific guidelines and continuous medical education regarding IPC may help improve the situation.

How to measure quantitative antibiotic use in order to support antimicrobial stewardship in acute care hospitals: a retrospective observational study

A cornerstone of antimicrobial stewardship programs (ASPs) is monitoring quantitative antibiotic use. Frequently used metrics are defined daily dose (DDD) and days of therapy (DOT). The purpose of this study was (1) to explore for the hospital setting the possibilities of quantitative data retrieval on the level of medical specialty and (2) to describe factors affecting the usability and interpretation of these quantitative metrics. We performed a retrospective observational study, measuring overall systemic antibiotic use at specialty level over a 1-year period, from December 1st 2014 to December 1st 2015, in one university and 13 non-university hospitals in the Netherlands. We distinguished surgical and non-surgical adult specialties. The association between DDDs, calculated from aggregated dispensing data, and DOTs, calculated from patient-level prescription data, was explored descriptively and related to organizational factors, data sources (prescription versus dispensing data), data registration, and data extraction. Twelve hospitals were able to extract dispensing data (DDD), three of which on the level of medical specialty; 13 hospitals were able to extract prescription data (DOT), 11 of which by medical specialty. A large variation in quantitative antibiotic use was found between hospitals and the correlation between DDDs and DOTs at specialty level was low. Differences between hospitals related to organizational factors, data sources, data registration, and data extraction procedures likely contributed to the variation in quantitative use and the low correlation between DDDs and DOTs. The differences in healthcare organization, data sources, data registration, and data extraction procedures contributed to the variation in reported quantitative use between hospitals. Uniform registration and extraction procedures are necessary for appropriate measurement and interpretation and benchmarking of quantitative antibiotic use.

Factors influencing antimicrobial prescribing by Dutch companion animal veterinarians: A qualitative study

Use of antimicrobials selects for antimicrobial resistance, and this poses a threat for both human and animal health. Although previous studies show that total antimicrobial use in Dutch companion animal clinics is relatively low and decreasing, the majority of antimicrobials prescribed are categorised as critically important for human medicine by the World Health Organization (WHO). Large differences in use between clinics are also observed. Identification of factors that influence the prescribing behaviour of veterinarians is needed to tailor future interventions aimed at promoting prudent use of antimicrobials in companion animals. The aim of this study was to explore factors influencing the antimicrobial prescribing behaviour of companion animal veterinarians in the Netherlands. Face-to-face, semi-structured interviews were used to interview 18 Dutch companion animal veterinarians. Interviews were held until theoretical data saturation was reached. An interview guide was used to structure the interviews, and ATLAS.ti 7.5 was used to manage and analyse the qualitative data. An iterative approach was applied to develop a conceptual model of factors that influence antimicrobial prescribing behaviour. The conceptual model shows four major categories of factors that influence the antimicrobial prescribing behaviour: veterinarian-related factors, patient-related (i.e. owner- and pet-related) factors, treatment-related factors (i.e. alternative treatment options and antimicrobial-related factors) and contextual factors (i.e. professional interactions, further diagnostics and environmental factors). All four major categories of influencing factors should be addressed to improve awareness on antimicrobial prescribing behaviour and to develop an antimicrobial stewardship programme for companion animal clinics.

Human resources required for antimicrobial stewardship teams: a Dutch consensus report

SCOPE

Antimicrobial stewardship teams are responsible for implementing antimicrobial stewardship programmes (ASP). However, in many countries, lack of funding challenges this obligation. A consensus procedure was performed to investigate which structural activities need to be performed by Dutch stewardship teams and how much time (and thus full-time equivalent (FTE) labor) is needed to perform these activities.

METHODS

In 2015, an electronic survey, based on a nonsystematic literature search and interviews with seven experienced stewardship teams, was sent to 21 stewardship teams that performed an ASP. This was followed by a semistructured face-to-face consensus meeting. Fourteen stewardship teams completed the survey (18% of Dutch acute-care hospitals), and 13 participated in the consensus meeting.

RECOMMENDATIONS

The hours needed each year are dependent on hospital size and number of stewardship objectives monitored. If all activities are performed at a minimal base (one stewardship objective; minimal staffing standard), time investment was estimated to be 1393 to 2680 hours annually in the early phase, corresponding with 0.87 (300 beds) to 1.68 FTE (1200 beds), with a further increase to minimally 1.25 to 3.18 FTE in the following years with three stewardship objectives monitored (optimal staffing standards during the first few years of implementing an ASP). This consensus on required human resources provides a directive for structural financial support of stewardship teams in the Dutch context. Some stewardship activities (and related time investments) might be specific to the Dutch context and hospital setting. To develop standards for other settings, our methodology could be applied.

The economic evaluation of an antibiotic checklist as antimicrobial stewardship intervention

Objectives

An antibiotic checklist was introduced in nine Dutch hospitals to improve appropriate antibiotic use. We estimated the cost-effectiveness of checklist use.

Methods

We compared 853 patients treated with an antibiotic before checklist introduction (usual care group) with 1207 patients treated after introduction (checklist group). We calculated the change of costs between these groups per unit effect [incremental cost-effectiveness ratio (ICER)]: per extra patient receiving appropriate treatment; and per day reduction in length of hospital stay (LOS). We also calculated the benefit-to-cost ratio per day reduction in LOS. Finally, we estimated the number of checklists after which the expected benefits would compensate for costs in one hospital.

Results

The cost of checklist use per patient was €10.10. Of the usual care patients, 48.8% received appropriate antibiotic treatment compared with 67.5% of the checklist patients (+18.7%). The ICER was €54.01 (1010/18.7) per extra patient with appropriate treatment. In a model calculation the expected effect of appropriate antibiotic use was a reduction in LOS of 1.05 days, which was extrapolated to a reduction of 19.64 hospital days per 100 patients. The ICER was €51.43 (1010/19.64) per day reduction in LOS. The estimated benefit of a 1 day reduction was €611. The benefit-to-cost ratio was 11.9 (611/51.43) per day reduction in LOS, indicating a cost saving of €12 for every euro spent on checklist use. The benefits would compensate for costs after use of 11 checklists.

Conclusions

Efforts for further implementation of the antibiotic checklist can be justified by potential economic benefits.

Development of a tailored strategy to improve postpartum hemorrhage guideline adherence

BACKGROUND

Despite the introduction of evidence based guidelines and practical courses, the incidence of postpartum hemorrhage shows an increasing trend in developed countries. Substandard care is often found, which implies an inadequate implementation in high resource countries. We aimed to reduce the gap between evidence-based guidelines and clinical application, by developing a strategy, tailored to current barriers for implementation.

METHODS

The development of the implementation strategy consisted of three phases, supervised by a multidisciplinary expert panel. In the first phase a framework of the strategy was created, based on barriers to optimal adherence identified among professionals and patients together with evidence on effectiveness of strategies found in literature. In the second phase, the tools within the framework were developed, leading to a first draft. In the third phase the strategy was evaluated among professionals and patients. The professionals were asked to give written feedback on tool contents, clinical usability and inconsistencies with current evidence care. Patients evaluated the tools on content and usability. Based on the feedback of both professionals and patients the tools were adjusted.

RESULTS

We developed a tailored strategy to improve guideline adherence, covering the trajectory of the third trimester of pregnancy till the end of the delivery. The strategy, directed at professionals, comprehending three stop moments includes a risk assessment checklist, care bundle and time-out procedure. As patient empowerment tools, a patient passport and a website with patient information was developed. The evaluation among the expert panel showed all professionals to be satisfied with the content and usability and no discrepancies or inconsistencies with current evidence was found. Patients' evaluation revealed that the information they received through the tools was incomplete. The tools were adjusted accordingly to the missing information.

CONCLUSION

A usable, tailored strategy to implement PPH guidelines and practical courses was developed. The next step is the evaluation of the strategy in a feasibility trial.

TRIAL REGISTRATION

Clinical trial registration: The Fluxim study, registration number: NCT00928863 .

The antibiotic checklist: an observational study of the discrepancy between reported and actually performed checklist items

Background

Checklists are increasingly used to measure quality of care. Recently we implemented an antibiotic checklist in nine Dutch hospitals and showed that use of the checklist resulted in more appropriate antibiotic use. While more appropriate antibiotic use was associated with a reduction in length of stay, use of the checklist in itself was not. In the current study we explored discrepancies between reported and actually performed checklist items at the patient level to test the validity of checklist answers, to evaluate whether discrepancies between reported and actually performed checklist items could explain the lack of effect of checklist use on length of stay, and to identify missed opportunities for performance per checklist item.

Methods

Checklist answers represented reported performance. Actual performance was assessed by data from the patients’ medical files. Reported and actually performed checklist items could be ‘both YES’; ‘both NO’; ‘YES reported, NOT actually performed’; or ‘NO reported, YES actually performed’. We determined an overall ‘both YES’ score per checklist, and used mixed models to evaluate whether an association existed between this overall score and patient’s length of hospital stay. Finally, we analysed whether the items that were not actually performed, could have been performed.

Results

Between January and October 2015 physicians filled in 1207 checklists. In total 7881 items were checked. Most items were ‘both YES’ (3392/7881, 43.0%) or ‘both NO’ (2601/7881, 33.0%). The number of ‘YES reported, NOT actually performed’ items was 1628/7881 (20.7%) compared to 260/7881 (3.3%) ‘NO reported, YES actually performed’ items. The level of discrepancy between reported and actually performed items differed per checklist item. The item ‘prescribe antibiotic treatment according to the local guideline’ had the highest percentage of ‘YES reported, NOT actually performed’ items, namely 45.1%. A higher overall ‘both YES’ score of the checklist was significantly associated with a shorter length of hospital stay. Of all checklist items 21.8% were not performed while they could have been performed.

Conclusions

Checklist answers do not accurately assess actual provided care. As actual performance of the antibiotic checklist items is associated with length of stay, efforts to increase actual performance appear to be justified.

Electronic supplementary material

The online version of this article (10.1186/s12879-017-2878-7) contains supplementary material, which is available to authorized users.

Development of an item bank to measure factual disease and treatment related knowledge of rheumatoid arthritis patients in the treat to target era

OBJECTIVE

To develop a Disease and treatment associated Knowledge in RA item bank (DataK-RA) based on item response theory.

METHODS

Initial items were developed from a systematic review. Rheumatology professionals identified relevant content trough a RAND modified Delphi scoring procedure and consensus meeting. RA patients provided additional content trough a focus group. Patients and professionals rated readability, feasibility and comprehensiveness of resulting items. Cross-sectional data were collected to evaluate psychometric properties of the items.

RESULTS

Data of 473 patients were used for item reduction and calibration. Twenty items were discarded based on corrected item-total point biserial correlation <0.30. Confirmatory factor analysis with weighted least squares estimation on the polychoric correlation matrix suggested good fit for a unidimensional model for the remaining 42 items (CFI 0.97 TLI=0.97, RMSEA=0.02, WRMR=0.97), supporting the proposed scoring procedure. Scores were highly reliable and normally distributed with minimal ceiling (1.8%) and no floor effects. 75% of tested hypotheses about the association of DataK-RA scores with related constructs were supported, indicating good construct validity.

CONCLUSION

DataK-RA is a psychometrically sound item bank.

PRACTICE IMPLICATIONS

DataK-RA provides health professionals and researchers with a tool to identify and target patients' information needs or to assess effects of educational efforts.

Implementation of the EULAR cardiovascular risk management guideline in patients with rheumatoid arthritis: results of a successful collaboration between primary and secondary care

The updated European League Against Rheumatism (EULAR) guideline recommends cardiovascular disease (CVD) risk assessment at least once every 5 years in all patients with rheumatoid arthritis (RA). This viewpoint starts with a literature overview of studies that investigated the level of CVD risk factor (CVD-RF) screening in patients with RA in general practices or in outpatient clinics. These studies indicate that CVD-RF screening in patients with RA is marginally applied in clinical practice, in primary as well as secondary care. Therefore, the second part of this viewpoint describes an example of the successful implementation of the EULAR cardiovascular disease risk management (CVRM) guideline in patients with RA in a region in the south of the Netherlands where rheumatologists and general practitioners (GPs) closely collaborate to manage the cardiovascular risk of patients with RA. The different components of this collaboration and the responsibilities of respectively primary and secondary care professionals are described. Within this collaboration, lipid profile was used as an indicator to assess whether CVD-RF screening was performed in the previous 5 years. In 72% (n=454) of the 628 patients with RA, a lipid profile was determined in the previous 5 years. As part of routine quality control, a reminder was sent to the GP in case a patient with RA was not screened. After sending the reminder letter, in 88% of all patients with RA, CVD risk assessment was performed. This collaboration can be seen as good practice to provide care in line with the EULAR guideline.

Appropriate antibiotic use reduces length of hospital stay

Objectives

To define appropriate antibiotic use in hospitalized adults treated for a bacterial infection, we previously developed and validated a set of six generic quality indicators (QIs) covering all steps in the process of antibiotic use. We assessed the association between appropriate antibiotic use, defined by these QIs, and length of hospital stay (LOS).

Methods

An observational multicentre study in 22 hospitals in the Netherlands included 1890 adult, non-ICU patients using antibiotics for a suspected bacterial infection. Performance scores were calculated for all QIs separately (appropriate or not), and a sum score described performance on the total set of QIs. We divided the sum scores into two groups: low (0%-49%) versus high (50%-100%). Multilevel analyses, correcting for confounders, were used to correlate QI performance (single and combined) with (log-transformed) LOS and in-hospital mortality.

Results

The only single QI associated with shorter LOS was appropriate intravenous-oral switch (geometric means 6.5 versus 11.2 days; P  < 0.001). A high sum score was associated with a shorter LOS in the total group (10.1 versus 11.2 days; P  = 0.002) and in the subgroup of community-acquired infections (9.7 versus 10.9 days; P  =   0.007), but not in the subgroup of hospital-acquired infections. We found no association between performance on QIs and in-hospital mortality or readmission rate.

Conclusions

Appropriate antibiotic use, defined by validated process QIs, in hospitalized adult patients with a suspected bacterial infection appears to be associated with a shorter LOS and therefore positively contributes to patient outcome and healthcare costs.

Antibiotic stewardship: does it work in hospital practice? A review of the evidence base

BACKGROUND

Guidelines for developing and implementing stewardship programmes include recommendations on appropriate antibiotic use to guide the stewardship team's choice of potential stewardship objectives. They also include recommendations on behavioural change interventions to guide the team's choice of potential interventions to ensure that professionals actually use antibiotics appropriately in daily practice.

AIMS

To summarize the evidence base of both appropriate antibiotic use recommendations (the 'what') and behavioural change interventions (the 'how') in hospital practice.

SOURCES

Published systematic reviews/Medline.

CONTENT

The literature shows low-quality evidence of the positive effects of appropriate antibiotic use in hospital patients. The literature shows that any behavioural change intervention might work to ensure that professionals actually perform appropriate antibiotic use recommendations in daily practice. Although effects were overall positive, there were large differences in improvement between studies that tested similar change interventions.

IMPLICATIONS

The literature showed a clear need for studies that apply appropriate study designs- (randomized) controlled designs-to test the effectiveness of appropriate antibiotic use on achieving meaningful outcomes. Most current studies used designs prone to confounding by indication. In the process of selecting behavioural change interventions that might work best in a chosen setting, much should be learned from behavioural sciences. The challenge for stewardship teams lies in selecting change interventions on the careful assessment of barriers and facilitators, and on a theoretical base while linking determinants to change interventions. Future studies should apply more robust designs and evaluations when assessing behavioural change interventions.

Reactive Rather than Proactive Diabetes Management in the Perioperative Period

As perioperative hyperglycemia is associated with poor postoperative patient outcomes, clinical guidelines provide recommendations for optimal perioperative glucose control. It is unclear to what extent recommended glucose levels are met in daily practice, and little is known about factors that influence these levels. We describe blood glucose levels throughout the hospital care pathway in 375 non-critically ill patients with diabetes who underwent major surgery (abdominal, cardiac, or orthopedic) in 6 hospitals, examine determinants of these levels including adherence to 9 quality indicators for optimal perioperative diabetes care, and perform qualitative interviews to identify barriers for optimal care. Virtually all patients (95%) experienced at least one hyperglycemic value (>10 mmol/l); 9% had at least one value <4 mmol/l. Mean glucose increased from preoperative to postoperative day (POD) 1 (+2.3 mmol/l, 5-95% CI 1.9-2.7), and then gradually decreased on POD 2-14 (+1.8 mmol/l, 5-95% CI 1.4-2.2). Insulin-treated patients (with or without oral agents) had higher glucose levels (+1.7 mmol/l, 5-95% CI 0.5-3.0, and +1.2 mmol/l, -0.1 to -2.5) than patients using oral agents only. Indicator adherence tended to be associated with higher glucose levels. Barriers for optimal care included a lack of formalized agreements on target glucose levels, absence of directly obvious disadvantages of hyperglycemia, and concern about inducing hypoglycemia. Hyperglycemia is common after major surgery, in particular on POD1 and in insulin-treated patients. Our results suggest that perioperative diabetes care is reactive rather than proactive, and that current emphasis of professionals is on treating instead of preventing postoperative hyperglycemia.

Clinical condition and comorbidity as determinants for blood culture positivity in patients with skin and soft-tissue infections

The utility of performing blood cultures in patients with a suspected skin infection is debated. We investigated the association between blood culture positivity rates and patients' clinical condition, including acute disease severity and comorbidity. We performed a retrospective study, including patients with cellulitis and wound infection who had been enrolled in three Dutch multicenter studies between 2011 and 2015. Patients' acute clinical condition was assessed using the Modified Early Warning Score (MEWS; severe: MEWS ≥2) and comorbidity with the Charlson Comorbidity Index (CCI; severe: CCI ≥2). A total of 334 patients with a suspected skin infection were included. Blood cultures were performed in 175 patients (52%), 28 of whom (16%) had a positive blood culture. Data on the clinical condition were collected in 275 patients. Blood cultures were performed in 76% of the patients with a severe acute condition, compared with 48% with a non-severe acute condition (OR 3.5; 95% confidence interval: 2.0-6.2; p < 0.001). Blood cultures were positive in 18% and 12% respectively (OR 1.7 (0.7-4.1); p = 0.3). Blood cultures were performed in 53% of patients with severe comorbidity, compared with 61% without severe comorbidity (OR 0.7; 0.4-1.2; p = 0.2). Blood cultures were positive in 25% and 10% respectively (OR = 3.1; 1.2-7.5; p = 0.02). The blood culture positivity rate among hospitalized patients diagnosed with skin infections was higher than the rates reported by the Infectious Diseases Society of America guidelines, particularly in patients with severe comorbidity. Therefore, the recommendations concerning blood culture performance in patients with a skin infection should be reconsidered.

Which recommendations are considered essential for outbreak preparedness by first responders?

BACKGROUND

Preparedness is considered essential for healthcare organizations to respond effectively to outbreaks. In the current study we aim to capture the views of first responders on what they consider key recommendations for high quality preparedness. Furthermore, we identified the recommendations with the highest urgency from the perspective of first responders.

METHODS

We chose a multistep approach using a systematic Delphi procedure. Previously extracted recommendations from scientific literature were presented to a national and two international expert panels. We asked the experts to score the recommendations based on relevance for high quality preparedness. In addition we asked them to choose the ten most urgent recommendations.

RESULTS

Starting with 80 recommendations from scientific literature, 49 key recommendations were selected by both international expert panels. Differences between both panels were mainly on triage protocols. In addition, large differences were found in the selection of the ten most urgent recommendations.

CONCLUSIONS

In this study infectious disease experts selected a set of key recommendations representing high quality preparedness and specified which ones should be given the highest urgency when preparing for a future crisis. These key recommendations can be used to shape their preparedness activities.

Impact of a multifaceted strategy to improve perioperative diabetes care

AIMS

To assess the impact of a multifaceted strategy to improve perioperative diabetes care throughout the hospital care pathway.

METHODS

We conducted a controlled before-and-after study in six hospitals. The purpose of the strategy was to target four predominant barriers that obstruct optimal care delivery. We provided feedback on baseline indicator performance, developed a multidisciplinary protocol and patient information, and provided professional education. After a 6-month intervention, we determined the performance changes against three outcome indicators and nine process indicators using data on 811 patients with diabetes who underwent major surgery. The progress of the interventions was monitored closely.

RESULTS

Two process indicators improved significantly in the intervention hospitals: the proportion of patients for whom glycaemic control had been evaluated preoperatively increased by 9% (P < 0.002) and the proportion of patients with blood glucose measurements within 1 h after surgery increased by 29% (P < 0.0001). Four other process indicators and all three outcome indicators improved more in the intervention hospitals than in the control hospitals, but the differences were not statistically significant. These included the proportion of patients with all glucose values at 6-10 mmol/l (+3%) and the proportion of patients with hyperglycaemia (-8%). The implementation of the multidisciplinary protocol was still ongoing after the 6-month intervention period.

CONCLUSIONS

The multifaceted improvement strategy had a limited impact on the quality of perioperative diabetes care. This study demonstrates the complexity of improving perioperative diabetes care throughout the multiprofessional hospital care pathway.

Effect of an antibiotic checklist on length of hospital stay and appropriate antibiotic use in adult patients treated with intravenous antibiotics: a stepped wedge cluster randomized trial

OBJECTIVES

Quality indicators (QIs) have been developed to define appropriate antibiotic use in hospitalized patients. We evaluated whether a checklist based on these QIs affects appropriate antibiotic use and length of hospital stay.

METHODS

An antibiotic checklist for patients treated with intravenous antibiotics was introduced in nine Dutch hospitals in a stepped wedge cluster randomized trial. Prophylaxis was excluded. We included a random sample before (baseline), and all eligible patients after (intervention) checklist introduction. Baseline and intervention outcomes were compared. Primary endpoint was length of stay (LOS), analysed by intention to treat. Secondary endpoints, including QI performances, QI sum score (performance on all QIs per patient), and quality of checklist use, were analysed per protocol.

RESULTS

Between 1 November 2014 and 1 October 2015 we included 853 baseline and 5354 intervention patients, of whom 993 (19%) had a completed checklist. The LOS did not change (baseline geometric mean 10.0 days (95% CI 8.6-11.5) versus intervention 10.1 days (95% CI 8.9-11.5), p 0.8). QI performances increased between +3.0% and +23.9% per QI, and the percentage of patients with a QI sum score above 50% increased significantly (OR 2.4 (95% CI 2.0-3.0), p<0.001). Higher QI sum scores were significantly associated with shorter LOS. Discordance existed between checklist-answers and actual performance.

CONCLUSIONS

Use of an antibiotic checklist resulted in a significant increase in appropriateness of antibiotic use, but not in a reduction of LOS. Low overall checklist completion rates and discordance between checklist-answers and actual provided care might have attenuated the impact of the checklist.

Assessing determinants of the intention to accept a pertussis cocooning vaccination: A survey among Dutch parents

INTRODUCTION

Pertussis cocooning is one of the strategies aiming to prevent the potential harm of pertussis in infants by vaccinating (among others) their parents. Several countries adopted this strategy, but uptake is a problem. Determinants of parental uptake are important in the design of an effective vaccination programme. Therefore, this study aims to assess parents' intention to accept a pertussis cocooning vaccination and its determinants.

METHODS

A 98 item questionnaire was developed based on a theoretical framework, assessing parents' intention to accept a pertussis cocooning vaccination and its personal and psychosocial determinants. In addition, beliefs underlying parents' attitude towards pertussis cocooning vaccination were assessed. Both logistic and linear regression analysis were used to assess univariate and multivariate associations amongst study variables.

RESULTS

Parents returned 282 questionnaires. The majority of the parents (78%) reported a positive intention to accept a pertussis cocooning vaccination. Attitude (OR 6.6, p<.001), anticipated negative affect in response to non acceptance (OR 1.65, p<.001), anticipated negative affect in response to acceptance (OR 0.55, p .040) and decisional uncertainty (OR 0.52, p .002) were significantly associated with intention. General vaccination beliefs (β 0.58, p<.001), moral norm (β 0.22, p<.001), perceived susceptibility of pertussis in children (β 0.10, p.004), and efficacy outcome expectations (β 0.15, p.011) were significant correlates of attitude towards pertussis cocooning vaccination.

CONCLUSION

The parental intention to accept a pertussis cocooning vaccination in this study is rather high. Targeting the identified determinants of parents' acceptance in a pertussis cocooning vaccination programme is crucial to secure that intention is translated into actual vaccination uptake.

Applicability of generic quality indicators for appropriate antibiotic use in daily hospital practice: a cross-sectional point-prevalence multicenter study

The ability to monitor the appropriateness of hospital antibiotic use is a key element of an effective antibiotic stewardship program. A set of 11 generic quality indicators (QIs) was previously developed to assess the quality of antibiotic use in hospitalized adults treated for a bacterial infection. The primary aim of the current study was to assess the clinimetric properties of these QIs (nine process and two structure indicators) in daily clinical practice. In a cross-sectional point-prevalence survey, performed in 2011 and 2012, 1890 inpatients from 22 hospitals in the Netherlands treated with antibiotics for a suspected bacterial infection were included, and data were extracted from medical records. In this cohort we tested the measurability, applicability, reliability, room for improvement and case mix stability of the previously developed QIs. Low applicability (≤10% of reviewed patients) was found for the QIs 'therapeutic drug monitoring', 'adapting antibiotics to renal function' and 'discontinue empirical therapy in case of lack of clinical and/or microbiological evidence of infection'. For the latter, we also found a low inter-observer agreement (kappa <0.4). One QI showed low improvement potential. The remaining seven QIs had sound clinimetric properties. Case-mix correction was necessary for most process QIs. For all QIs, we found ample room for improvement and large variation between hospitals. Establishing the clinimetric properties was essential, as four of the 11 previously selected QIs showed unsatisfactory properties in this practice test. Since the quality of antibiotic use and the process of documenting data is changing over time and may vary per country, QIs should always be tested in practice first.

Practice what you preach? An exploratory multilevel study on rheumatoid arthritis guideline adherence by rheumatologists

Objectives

To assess variation in and determinants of rheumatologist guideline adherence in patients with rheumatoid arthritis (RA), in daily practice.

Methods

In this retrospective observational study, guideline adherence in the first year of treatment was assessed for 7 predefined parameters on diagnostics, treatment and follow-up in all adult patients with RA with a first outpatient clinic visit at the study centre, from September 2009 to March 2011. Variation in guideline adherence was assessed on parameter and rheumatologist level. Determinants for guideline adherence were assessed in patients (demographic characteristics, rheumatoid factor (RF) and/or anti-cyclic citrullinated peptide antibody (aCCP) positivity, erythrocyte sedimentation rate, erosive disease, comorbidity and the number of available disease modifying anti-rheumatic drug (DMARD) treatment options) and rheumatologists (demographic and practice characteristics, guideline knowledge and agreement, outcome expectancy, cognitive bias, thinking style, numeracy and personality).

Results

A total of 994 visits in 137 patients with RA were reviewed. Variation in guideline adherence among parameters was present (adherence between 21% and 72%), with referral to the physician assistant as lowest scoring and referral to a specialised nurse as highest scoring parameter. Variation in guideline adherence among rheumatologists was also present (adherence between 22% and 100%). Patient sex, the number of DMARD options, presence of erosions, comorbidity, RF/aCCP positivity, type of patient and the rheumatologists' scientific education status were associated with adherence to 1 or more guideline parameters.

Conclusions

Guideline adherence varied considerably among the guideline parameters and rheumatologists, showing that there is room for improvement. Guideline adherence in our sample was related to several patient and rheumatologist determinants.

Intention to Accept Pertussis Vaccination for Cocooning: A Qualitative Study of the Determinants

Context

Several countries have reported a resurgence of pertussis in the last decades. This puts infants (especially <6 months) at risk of severe complications, because they are too young to be fully protected by vaccination. The global pertussis initiative has proposed pertussis vaccination of young infants’ close contacts, in order to reduce pertussis transmission and the burden of the disease on infants. Our aim is to explore the perceived determinants (barriers and facilitators) of intention to accept vaccination among the possible target groups of pertussis vaccination for cocooning. Consideration of these determinants is necessary to optimise the uptake of the vaccination.

Methods

We conducted 13 focus groups and six individual semi-structured interviews with members of possible target groups for pertussis cocooning (i.e. parents, maternity assistants, midwives, and paediatric nurses) in the Netherlands. Here, both maternal pertussis vaccination as well as pertussis cocooning has not been implemented. The topic list was based on a literature review and a barrier framework. All interviews were transcribed verbatim and two researchers performed thematic content analysis.

Findings

The participants’ risk perception, outcome expectations, general vaccination beliefs, moral norms, opinion of others, perceived autonomy, anticipated regret, decisional uncertainty, and perceived organisational barriers were all factors that influenced the intention to accept pertussis vaccination for cocooning.

Discussion

This study has identified nine perceived determinants that influence the intention to accept pertussis cocooning vaccination. We add the following determinants to the literature: perceived cost-effectiveness (as a concept of outcome expectations), justice (as a concept of moral norms), anticipated regret, and decisional uncertainty. We recommend considering these determinants in vaccination programmes for pertussis cocooning vaccination. Experience, information and trust emerged as predominant themes within these determinants. These themes require particular attention in future research on vaccination acceptance, especially with regard to their role in use and implementation in policy and practice.

The value of routine creatine kinase and thyroid stimulating hormone testing in patients with suspected fibromyalgia: a cross-sectional study

OBJECTIVE

The aim was to examine the prevalence of abnormal creatine kinase (CK) and thyroid stimulating hormone (TSH) values and previously unknown myopathy or thyroid disease in patients with suspected FM syndrome (FMS).

METHODS

All adult patients with suspected FMS referred to the study hospital between November 2011 and April 2014 could participate. Patients with a history of myopathy or a previous diagnosis of thyroid disorder were excluded. Outcome measures were the percentages of abnormal CK and TSH values and the final diagnosis in those patients.

RESULTS

Three hundred and seventy-three patients were included in this study (94% female, mean age 42 years). Of these patients, 7.5% (95% CI: 5.2, 10.6%) had an abnormal CK according to the local reference values. Applying the European Federation of the Neurological Societies guideline, this changed to 0.5% (95% CI: 0.2, 1.9%). In none of these patients was hyperCKaemia-related myopathy diagnosed, and the final diagnosis was FMS in 89% of the patients. Of the total number of patients, 3.5% (95% CI: 2.1, 5.9%) had an elevated TSH and 1.4% (95 CI: 0.6, 3.1%) a lowered TSH, with one patient having a somewhat lowered free thyroid hormone level. The final diagnosis was FMS in all these patients.

CONCLUSION

Abnormal CK and TSH values are rare in patients with suspected FMS and do not result in an alternative diagnosis. Therefore, it seems that routine testing of CK and TSH levels in patients with suspected FMS referred to secondary care does not contribute to the diagnostic process.

A survey to identify barriers of implementing an antibiotic checklist

A checklist is an effective implementation tool, but addressing barriers that might impact on the effectiveness of its use is crucial. In this paper, we explore barriers to the uptake of an antibiotic checklist that aims to improve antibiotic use in daily hospital care. We performed an online questionnaire survey among medical specialists and residents with various professional backgrounds from nine Dutch hospitals. The questionnaire consisted of 23 statements on anticipated barriers hindering the uptake of the checklist. Furthermore, it gave the possibility to add comments. We included 219 completed questionnaires (122 medical specialists and 97 residents) in our descriptive analysis. The top six anticipated barriers included: (1) lack of expectation of improvement of antibiotic use, (2) lack of expected patients' satisfaction by checklist use, (3) lack of feasibility of the checklist, (4) negative previous experiences with other checklists, (5) the complexity of the antibiotic checklist and (6) lack of nurses' expectation of checklist use. Remarkably, 553 comments were made, mostly (436) about the content of the checklist. These insights can be used to improve the specific content of the checklist and to develop an implementation strategy that addresses the identified barriers.

[Better antibiotic use in complicated urinary tract infections; multicentre cluster randomised trial of 2 improvement strategies]

OBJECTIVE

To compare the effectiveness of two strategies to improve antibiotic use in patients with a complicated urinary tract infection.

DESIGN

Multicentre cluster randomised unblinded trial.

METHOD

The departments of Internal Medicine and Urology from 19 hospitals in the Netherlands took part in this trial. Based on retrospective patient record investigations we performed baseline measurements on the scores of a validated set of quality indicators for antibiotic use in a minimum of 50 patients with a complicated urinary tract infection per department in 2009. A similar post-trial measurement took place in 2012. In 2010 we randomised the hospitals between 2 improvement strategies: a multifaceted strategy that included results of the baseline measurements, education, reminders and assistance with optional improvement interventions, and a competitive feedback strategy, in which the departments only received results of the baseline measurements and non-anonymous results from the other departments in this study arm. The primary outcome measure was improvement of the quality indicator scores. Secondary outcome measures were determinants of improvement of the indicators. (Netherlands Trial Register: NTR1742) RESULTS: The baseline and post-trial measurements were performed on 1,964 patients and 2,027 patients, respectively. Post-trial measurements revealed a significant, but limited, improvement of several indicators compared with baseline measurements. We found no significant difference in improvement between the two strategies for any indicator. The intensity with which the departments implemented improvement strategies was mostly suboptimal, but intensive implementation of a strategy was associated with greater improvement.

CONCLUSION

The effectiveness of both improvement strategies was comparable, but limited. For real improvement in antibiotic use in patients with complicated urinary tract infections, improvement interventions should be developed and applied by local professionals themselves.