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Evaluation of carbapenem-resistant Enterobacteriaceae (CRE) guideline implementation in the Veterans Affairs Medical
Cassie Cunningham Goedken1, Marylou Guihan2,3, Charnetta R Brown4
1Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, 152, 601 Highway 6 West, Iowa City, IA, 52246, USA. cassie.goedken@va.gov.
Insights
Implementing carbapenem-resistant Enterobacteriaceae (CRE) guidelines requires leadership engagement and resources. Effective CRE control relies on collaboration among specialists and improved communication strategies.
Area of Science:
- Infectious Diseases
- Healthcare Management
- Implementation Science
Background:
- Carbapenem-resistant Enterobacteriaceae (CRE) infections pose a significant mortality risk in healthcare settings.
- The Veterans Health Administration (VHA) issued guidelines in 2015 and 2017 to control CRE, focusing on laboratory testing, prevention, and management.
- The Consolidated Framework for Implementation Research (CFIR) was employed to analyze factors influencing guideline implementation in VA Medical Centers (VAMCs).
Purpose of the Study:
- To identify CFIR constructs for improving CRE guideline/directive implementation.
- To understand how the multi-level CFIR model can inform guideline implementation strategies.
- To analyze qualitative data from VAMCs regarding CRE control measures.
Main Methods:
- Semi-structured interviews were conducted with 29 VAMCs staff involved in CRE guideline implementation.
- Survey and VHA administrative data identified VAMCs for interviews based on size and CRE incidence.
- Qualitative data were coded using a mixed deductive-inductive approach guided by CFIR, with quantitative analysis comparing CFIR constructs to screening practices and CRE-positive cultures.
Main Results:
- Interviews with 43 staff revealed needs for standardized communication tools (e.g., electronic screening) and CRE-specific educational materials.
- Quantitative analysis linked CRE screening or presence to CFIR constructs: leadership engagement, relative priority, available resources, team communication, and access to knowledge/information.
- Key personnel interviewed included laboratory staff, Multi-Drug-Resistant Organism Program Coordinators (MPCs), infection preventionists, and physicians.
Conclusions:
- Successful CRE identification, prevention, and treatment necessitate collaboration among clinical, microbiology, infection prevention, antimicrobial stewardship, and infectious diseases specialists.
- Leadership engagement is crucial for fostering a positive facility culture, ensuring resource availability, enhancing communication, and driving successful CRE guideline implementation.
- The study highlights the importance of multi-level factors, as defined by CFIR, in the effective implementation of infectious disease control guidelines.
Background:
Infections caused by carbapenem-resistant Enterobacteriaceae (CRE) and carbapenemase-producing (CP) CRE are difficult to treat, resulting in high mortality in healthcare settings every year. The Veterans Health Administration (VHA) disseminated guidelines in 2015 and an updated directive in 2017 for control of CRE focused on laboratory testing, prevention, and management. The Consolidated Framework for Implementation Research (CFIR) framework was used to analyze qualitative interview data to identify contextual factors and best practices influencing implementation of the 2015 guidelines/2017 directive in VA Medical Centers (VAMCs). The overall goals were to determine CFIR constructs to target to improve CRE guideline/directive implementation and understand how CFIR, as a multi-level conceptual model, can be used to inform guideline implementation.
Methods:
Semi-structured interviews were conducted at 29 VAMCs with staff involved in implementing CRE guidelines at their facility. Survey and VHA administrative data were used to identify geographically representative large and small VAMCs with varying levels of CRE incidence. Interviews addressed perceptions of guideline dissemination, laboratory testing, staff attitudes and training, patient education, and technology support. Participant responses were coded using a consensus-based mixed deductive-inductive approach guided by CFIR. A quantitative analysis comparing qualitative CFIR constructs and emergent codes to sites actively screening for CRE (vs. non-screening) and any (vs. no) CRE-positive cultures was conducted using Fisher's exact test.
Results:
Forty-three semi-structured interviews were conducted between October 2017 and August 2018 with laboratory staff (47%), Multi-Drug-Resistant Organism Program Coordinators (MPCs, 35%), infection preventionists (12%), and physicians (6%). Participants requested more standardized tools to promote effective communication (e.g., electronic screening). Participants also indicated that CRE-specific educational materials were needed for staff, patient, and family members. Quantitative analysis identified CRE screening or presence of CRE as being significantly associated with the following qualitative CFIR constructs: leadership engagement, relative priority, available resources, team communication, and access to knowledge and information.
Conclusions:
Effective CRE identification, prevention, and treatment require ongoing collaboration between clinical, microbiology, infection prevention, antimicrobial stewardship, and infectious diseases specialists. Our results emphasize the importance of leadership's role in promoting positive facility culture, including access to resources, improving communication, and facilitating successful implementation of the CRE guidelines.