Health Care Innovation and Quality Assurance

Collection of articles on Health Care Innovation and Quality Assurance is available here.
Facilitators and Challenges Experienced by Nursing Homes Enrolling in the CDC National Healthcare Safety Network.
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B. I. Braun, B. A. Longo, R. Thomas, et al.
Am J Infect Control 2020 Sep 2
Standardized measurement of healthcare-associated infections is essential to improving nursing home (NH) resident safety, however voluntary enrollment of NHs in Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN) requires several steps. We sought to prospectively identify NH structural, process or staff characteristics that affect enrollment and data submission among a cohort of NHs receiving facilitated implementation. METHODS: The evaluation employed a mixed methods approach. The meta-theoretical Consolidated Framework for Implementation Research was used to analyze reported facilitators and challenges. Primary and secondary outcomes were time to NHSN enrollment and data submission, respectively. RESULTS: Of 36 participating NHs, 27 (75%) completed NHSN enrollment and 21 (58%) submitted one or more months of infection data during the 8-month study period. Mean days to complete enrollment was 82 (SD=24, range=51-139) and days to first data submission was 112 (SD=45, range=71-245). Characteristics of NH staff liaisons associated with shorter time to enrollment included infection prevention and control (IPC) knowledge, personal confidence, and responsibility for IPC activities. Facility characteristics were not associated with outcomes. DISCUSSION: Time to NHSN enrollment and submission related more to characteristics of the person leading the process than to characteristics of the NH. CONCLUSIONS: External partnerships that provide real-time support and resources are important assets in promoting successful NH participation in NHSN.

From evidence to practice: Developing best practice guidelines for the delivery of activities to people living with moderate to advanced dementia using a pragmatic observational study.
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A. Burke, A. Jones, R. Hughes and E. Player.
Dementia (London) 2020 Sep 5:1471301220957805
The benefits of physical activities for those living with moderate to advanced dementia are well documented and include improved well-being and quality of life. What is less well known is how best to deliver such activities to make them meaningful for those taking part and, more generally, how to develop good practice guidance for working with this group. This article reports on an observational study of a physical activity programme in a residential care setting, Mobile Me, and on the process used to develop good practice guidance from it, which included input from a range of stakeholders. Learnings from this study conclude that changes in delivery and setting can contribute to a difference in the quality of the experience for participants and their levels of well-being during sessions. The findings from the study were consolidated into four themes for disseminating best practice: promoting the right atmosphere, environment, communication, and adaptations. These form part of a new multimedia best practice guide for delivering physical activities to those living with moderate to advanced dementia.

Palliative care delivery in residential aged care: bereaved family member experiences of the Supportive Hospice Aged Residential Exchange (SHARE) intervention.
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R. Frey, S. Barham, D. Balmer, M. Boyd, J. Robinson and M. Gott.
BMC Palliat Care 2020 Aug 17;19(1):127-020-00633-x
The supportive hospice aged residential exchange (SHARE) is a new model of palliative care education that has been designed for residential aged care. The goal of SHARE is to help clinical staff improve palliative care within residential aged care facilities and to improve specialist palliative care nurses’ knowledge and skill to care for frail older people. METHOD: The experiences of 18 bereaved families concerning the palliative care journey (both at the start and finish of a one-year implementation of SHARE) were explored using semi-structured interviews. RESULTS: Three themes were important to bereaved families’ experience: communication with staff, systems of care, and hospice involvement. Sub-themes indicating changes in these three components of care between the start and finish of SHARE was identified. A fourth theme highlighted challenges (relationship with GP, staff shortages, and turnover) that continued across SHARE. CONCLUSION: Findings indicated that SHARE benefited families (improved communication and support) through the end of life journey of their relatives, but challenges remained.

Influencing duration of antibiotic therapy: A behavior change analysis in long-term care.
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B. J. Langford, J. Quirk, S. Carey, N. Daneman and G. E. Garber.
Am J Infect Control 2019 Dec;47(12):1409-1414
Prolonged antibiotic duration of therapy is common in long-term care (LTC) settings and associated with increased risk of harm for residents. To identify potential antibiotic stewardship opportunities aimed at prolonged duration of therapy, this study examined barriers and enablers to using shorter courses of antibiotic therapy in the LTC setting. METHODS: Semistructured interviews were conducted with prescribers in LTC home settings, and a total of 8 LTC clinicians participated in the study. Questions and clinical scenarios explored the factors influencing the decisions of prescribers about duration of therapy. Using the Theoretical Domains Framework, interview data were analyzed deductively. RESULTS: The themes identified that influence duration of antibiotic therapy in LTC were environmental context and resources, knowledge, beliefs about consequences, social influences, and behavioral regulation. Specific concerns described by participants included the perceived lack of evidence to support shorter courses in LTC residents, the misconception that shorter courses could lead to greater rates of resistance, and the strong role of habit and prior experience in selecting antibiotic duration. DISCUSSION: There are several factors affecting antimicrobial duration prescribing behavior aside from the clinical scenario itself. Tackling misconceptions and providing educational support may be helpful approaches. CONCLUSIONS: These findings provide theory-informed evidence to support the development of antimicrobial stewardship interventions aimed at improving duration of antibiotic therapy.

The Impact of Implementing a Namaste Care Intervention in UK Care Homes for People Living with Advanced Dementia, Staff and Families.
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I. Latham, D. Brooker, J. Bray, N. Jacobson-Wright and F. Frost.
Int J Environ Res Public Health 2020 Aug 18;17(16):E6004. doi: 10.3390/ijerph17166004
Care homes can struggle to provide optimal care for residents with advanced dementia. Namaste Care provides a structured daily programme of physical, sensory and emotional care delivered by regular care workers. A three-year, mixed method process study of implementation and impact created a manualised Namaste Care Intervention for UK care homes (NCI-UK). This article reports on the impact of NCI-UK delivered consistently in five care homes for 12-24 weeks. Impact for residents was assessed using, pre-post data, showing significant positive effects for QUALID (t = 2.92, p = 0.01, n = 31) and CMAI (t = 3.31, p = 0.002, n = 32), alongside many qualitative examples of positive impacts on wellbeing, responsiveness and communication. Pre-post staff questionnaire data (n = 20) were not significant. Qualitative data indicated that NCI-UK is a positive staff experience, providing sense of purpose, improved wellbeing and relationships. The care homes reported benefiting from implementing NCI-UK in terms of reputation and quality improvement. Family interviews were also positive, relating to seeing the difference, improving relationships and being involved. NCI-UK can therefore be recommended as an impactful intervention for residents, staff and families.

Selected aspects of the knowledge and practice concerning hand hygiene guidelines in the context of infection control structures in hospitals and long-term care facilities – findings of a questionnaire survey.
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G. Puto, J. Wójkowska-Mach, M. Wałszek, I. B. Repka and A. Różańska.
Med Pr 2020 Aug 26
Hand hygiene (HH) is the simplest and the most fundamental means of hospital-acquired infection (HAI) prevention in both hospitals and long-term care facilities (LTCFs) which differ as to their structure, organization and epidemiology. The objective of this study was to evaluate the knowledge of, and attitudes towards, compliance with the HH guidelines by medical staff of LTCFs and hospitals, in the context of infection control organization. MATERIAL AND METHODS: The study was carried out among medical staff of LTCFs and hospitals using an anonymous questionnaire designed by the authors. The questionnaire was composed of 22 questions. RESULTS: Among 237 healthcare workers from LTCFs and hospitals (51.5% vs. 48.5%), the vast majority were women (97.5% vs. 94.8%), who were nurses (86.9% vs. 91.3%) with 21-30 years of experience (28.5% vs. 44.3%). The respondents, both working in hospitals and in LTCFs, declared that there was some surveillance of HAIs in their workplace – 78.8% vs. 87.8%, respectively, p = 0.082. However, the respondents from LTCFs significantly more often than those working in hospitals declared the lack of HAI registration (12.3% vs. 0.9%, p = 0.002), as well as the lack of surveillance of multidrug-resistant microorganisms (16.4% vs. 4.3%, p = 0.010). Although the knowledge of WHO HH guidelines was declared by over 90% of the respondents, only about 70% of them (with no significant difference between both types of facilities) properly indicated the 5 moments of HH. CONCLUSIONS: The results of the study indicate that the organizational conditions and practice of HH in LTCFs and hospitals present some differences. Therefore, there is a need for observational studies concerning HH in the context of the structure and organization of infection control, as they are necessary for the development and implementation of effective programs to improve the situation in this field.

Measuring readiness for implementation: A systematic review of measures’ psychometric and pragmatic properties.
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Bryan J. Weiner, Kayne D. Mettert, Caitlin N. Dorsey, et al.
Implementation Research and Practice 2020 01/01; 2020/09;1:2633489520933896
Systematic measure reviews can facilitate advances in implementation research and practice by locating reliable, valid, pragmatic measures; identifying promising measures needing refinement and testing; and highlighting measurement gaps. This review identifies and evaluates the psychometric and pragmatic properties of measures of readiness for implementation and its sub-constructs as delineated in the Consolidated Framework for Implementation Research: leadership engagement, available resources, and access to knowledge and information.Methods:The systematic review methodology is described fully elsewhere. The review, which focused on measures used in mental or behavioral health, proceeded in three phases. Phase I, data collection, involved search string generation, title and abstract screening, full text review, construct assignment, and cited citation searches. Phase II, data extraction, involved coding relevant psychometric and pragmatic information. Phase III, data analysis, involved two trained specialists independently rating each measure using Psychometric and Pragmatic Evidence Rating Scales (PAPERS). Frequencies and central tendencies summarized information availability and PAPERS ratings.Results:Searches identified 9 measures of readiness for implementation, 24 measures of leadership engagement, 17 measures of available resources, and 6 measures of access to knowledge and information. Information about internal consistency was available for most measures. Information about other psychometric properties was often not available. Ratings for internal consistency were ?adequate? or ?good.? Ratings for other psychometric properties were less than ?adequate.? Information on pragmatic properties was most often available regarding cost, language readability, and brevity. Information was less often available regarding training burden and interpretation burden. Cost and language readability generally exhibited ?good? or ?excellent? ratings, interpretation burden generally exhibiting ?minimal? ratings, and training burden and brevity exhibiting mixed ratings across measures.Conclusion:Measures of readiness for implementation and its sub-constructs used in mental health and behavioral health care are unevenly distributed, exhibit unknown or low psychometric quality, and demonstrate mixed pragmatic properties. This review identified a few promising measures, but targeted efforts are needed to systematically develop and test measures that are useful for both research and practice.Plain language abstract:Successful implementation of effective mental health or behavioral health treatments in service delivery settings depends in part on the readiness of the service providers and administrators to implement the treatment; the engagement of organizational leaders in the implementation effort; the resources available to support implementation, such as time, money, space, and training; and the accessibility of knowledge and information among service providers about the treatment and how it works. It is important that the methods for measuring these factors are dependable, accurate, and practical; otherwise, we cannot assess their presence or strength with confidence or know whether efforts to increase their presence or strength have worked. This systematic review of published studies sought to identify and evaluate the quality of questionnaires (referred to as measures) that assess readiness for implementation, leadership engagement, available resources, and access to knowledge and information. We identified 56 measures of these factors and rated their quality in terms of how dependable, accurate, and practical they are. Our findings indicate there is much work to be done to improve the quality of available measures; we offer several recommendations for doing so.

Effectiveness of a Mouth Care Program Provided by Nursing Home Staff vs Standard Care on Reducing Pneumonia Incidence: A Cluster Randomized Trial.
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S. Zimmerman, P. D. Sloane, K. Ward, et al.
JAMA Netw Open 2020 Jun 1;3(6):e204321
Pneumonia affects more than 250 000 nursing home (NH) residents annually. A strategy to reduce pneumonia is to provide daily mouth care, especially to residents with dementia. OBJECTIVE: To evaluate the effectiveness of Mouth Care Without a Battle, a program that increases staff knowledge and attitudes regarding oral hygiene, changes mouth care, and improves oral hygiene, in reducing the incidence of pneumonia among NH residents. DESIGN, SETTING, AND PARTICIPANTS: This pragmatic cluster randomized trial observing 2152 NH residents for up to 2 years was conducted from September 2014 to May 2017. Data collectors were masked to study group. The study included 14 NHs from regions of North Carolina that evidenced proportionately high rehospitalization rates for pneumonia and long-term care residents. Nursing homes were pair matched and randomly assigned to intervention or control groups. INTERVENTION: Mouth Care Without a Battle is a standardized program that teaches that mouth care is health care, provides instruction on individualized techniques and products for mouth care, and trains caregivers to provide care to residents who are resistant and in special situations. The control condition was standard mouth care. MAIN OUTCOMES AND MEASURES: Pneumonia incidence (primary) and hospitalization and mortality (secondary), obtained from medical records. RESULTS: Overall, the study enrolled 2152 residents (mean [SD] age, 79.4 [12.4] years; 1281 [66.2%] women; 1180 [62.2%] white residents). Participants included 1219 residents (56.6%) in 7 intervention NHs and 933 residents (43.4%) in 7 control NHs. During the 2-year study period, the incidence rate of pneumonia per 1000 resident-days was 0.67 and 0.72 in the intervention and control NHs, respectively. Neither the primary (unadjusted) nor secondary (covariate-adjusted) analyses found a significant reduction in pneumonia due to Mouth Care Without a Battle during 2 years (unadjusted incidence rate ratio, 0.90; upper bound of 1-sided 95% CI, 1.24; P = .27; adjusted incidence rate ratio, 0.92; upper bound of 1-sided 95% CI, 1.27; P = .30). In the second year, the rate of pneumonia was nonsignificantly higher in intervention NHs. Adjusted post hoc analyses limited to the first year found a significant reduction in pneumonia incidence in intervention NHs (IRR, 0.69; upper bound of 1-sided 95% CI, 0.94; P = .03). CONCLUSIONS AND RELEVANCE: This matched-pairs cluster randomized trial of a mouth care program compared with standard care was not effective in reducing pneumonia incidence at 2 years, although reduction was found during the first year. The lack of significant results in the second year may be associated with sustainability. Improving mouth care in US NHs may require the presence and support of dedicated oral care aides. TRIAL REGISTRATION: Identifier: NCT03817450.

Implementing Evidence-Based Pressure Injury Prevention Interventions: Veterans Health Administration Quality Improvement Collaborative.
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L. Zubkoff, J. Neily, S. McCoy-Jones, et al.
J Nurs Care Qual 2020 Aug 27
Pressure injury prevention is a persistent concern in nursing. The Veterans Health Administration implemented a creative approach with successful outcomes across the United States. PROBLEM: Pressure injury prevention is a measure of nursing quality of care and a high priority in the Veterans Health Administration. METHODS: A 12-month Virtual Breakthrough Series Collaborative utilizing coaching and group calls was conducted to assist long-term and acute care teams with preventing pressure injuries. INTERVENTIONS: Interventions from the Veterans Health Administration Skin Bundle were implemented, including pressure-relieving surfaces, novel turning techniques, specialized dressings, and emollients to prevent skin breakdown. RESULTS: The aggregated pressure injury rate for all teams decreased from Prework to the Action phase from 1.0 to 0.8 per 1000 bed days of care (P = .01). The aggregated pressure injury rates for long-term care units decreased from Prework to Continuous Improvement from 0.8 to 0.4 per 1000 bed days of care (P = .021). CONCLUSION: The Virtual Breakthrough Series helped reduce pressure injuries.