Infection Control & Hospital Epidemiology
Methods Study design
Over a 28-month period, a quasi-experimental study was con- ducted in 6 outpatient dialysis facilities in the New Jersey area. The size of the facilities ranged from 35 to 95 patients. The antimicrobial stewardship program was implemented from July 1, 2015, to October 31, 2016, of which the first 4 months were considered the wash-out period, during which time the inter- vention was introduced. Rates of antimicrobial use per 100 patient months were compared to the 12-month preintervention period from July 1, 2014, to June 30, 2015. Data on antimicrobial use, patient demographics, comorbidities and clinical data were collected from the central electronic medical record database. The primary outcome was the monthly incidence rate of intravenous antimicrobial doses administered per 100 patient months. Sec- ondary outcomes included rates of use for specific antimicrobials or antimicrobial groups. Negative outcomes, potentially asso- ciated with the implementation of an antimicrobial stewardship program, included rates of BSI and hospitalization because a decreased use of antimicrobials as a result of the program could potentially lead to increased rates of hospitalization or infection. Confounders included rate of tunneled catheters (because patients with catheters receive more antimicrobials than those without),12 the rate of methicillin-resistant Staphylococcus aureus BSI (because these would warrant vancomycin therapy), and the composite of facility-level quality measures: albumin, hemoglo- bin, phosphorus and calcium values, no catheter exposure >90 days, hospitalizations, readmissions and mortality rates. Higher values were more favorable. The Institutional Review Board of the Rhode Island Hospital and the organization approved this study. Informed consent was waived.
Antimicrobial stewardship program
The antimicrobial stewardship program had 4 main components. First, leadership support was obtained through discussions during one-on-one meetings and the unit-based program leader (ie, the nurse manager) in each unit was identified. Second, educational programs were conducted and led by the nurse educator, including didactic and informal sessions at each unit, which emphasized the overall importance of improving antimicrobial prescribing patterns. All unit staff members, including physicians, physician assistants, nurse practitioners, dialysis technicians, dieticians, and social workers, were invited to these unit-based sessions. A separate educational session was provided to the medical directors. These sessions focused on 3 areas previously identified as the most common reasons for inappropriate pre- scribing: (1) criteria for starting antimicrobials for a presumed BSIs, (2) criteria for diagnosing skin and soft-tissue infections, and (3) de-escalation or narrowing of antimicrobials (eg, from vancomycin to cefazolin in a patient with a methicillin-susceptible Staphylococcus aureus [MSSA] infection or from third- or fourth- generation cephalosporins to cefazolin in a patient with a cefazolin-susceptible bacterial infection).10 Educational posters and pocket cards containing the criteria for appropriate anti- microbial prescribing were also provided. Third, conference calls were conducted with all 6 clinical managers program leaders and the research personnel, including the infectious disease physician. During these monthly calls, review of all antimicrobial courses prescribed in the previous month were reviewed, focusing on indication for prescribing and type of antimicrobial prescribed.
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Recommendations were discussed for optimizing prescribing using national consensus guidelines by major infectious disease and nephrology societies.10,13–26 During each call, the importance of reviewing microbiology reports and antimicrobial susceptibility data, to de-escalate antimicrobials, was emphasized. Feedback regarding prescribing practices was also provided during these calls. Lastly, to facilitate the engagement of all healthcare workers and to promote a cultural transformation in antimicrobial pre- scribing, the positive deviance process was implemented. Positive deviance is a social and behavioral change process founded on the observations that there are individuals in organizations whose uncommon (deviant) practices generate better (positive) results than those of their peers.27 The process differs from most tradi- tional improvement methods, which depend on the creation of new process or importation of best practices developed elsewhere. Positive deviance is predicated on the beliefs that expertise for change resides in all organizations, change is best guided by those with knowledge of an organization’s culture and norms, and widespread diffusion of new practices depends on widespread involvement of frontline staff in the improvement process. This behavioral strategy was part of a Centers for Disease Control and Prevention hemodialysis BSI prevention collaborative, which resulted in a substantial decrease in rates of BSI.28 The basic steps of the positive deviance process were (1) defining the problem and establishing goals; (2) determining whether there are staff, the positive deviants, who are achieving better outcomes than others; (3) discovering the behaviors and strategies that enable the positive deviants to achieve the better outcomes; and (4) pro- viding the opportunity for staff to practice the positive deviance behaviors and strategies. Implementation of these steps included discovery and action dialogues sessions. These small group con- versations were held in all 6 facilities and were designed to help staff uncover and learn about positive deviant practice behaviors and strategies that would help ensure appropriate antimicrobial prescribing.29 Clinical scenarios were also developed by staff to demonstrate positive deviance behaviors and to provide oppor- tunity for the staff to practice these behaviors by engaging in role play. The overall process was facilitated by research personnel with
expertise in infectious disease and antimicrobial use in dialysis settings (E.M.C.D.), positive deviance (C.C.L., C.M.L., and G.D.), nursing education (C.L.), and infection prevention (G.D.). Adaptation of the process to the participating dialysis facilities and important implementation details were guided by a steering committee comprised of the regional director of operations and clinical managers from each site.
Statistical analyses
Rates of antimicrobial use per 100 patient months were calculated for the preintervention and intervention periods, resulting in 24 data points. The 4-month wash-out period was not included in the analyses. A segmented regression analysis of this interrupted time-series study was performed using an overdispersed Poisson mixed-effects model of monthly data, where random effects accounted for clinic correlation (ie, the Glimmix procedure) using SAS Enterprise Guide version 7.1 software (SAS Institute, Cary, NC). An interrupted time-series design is the strongest quasi- experimental approach to evaluate longitudinal effects of an intervention.30,31 The segmented regression models were further adjusted for seasonality. Standardized effect sizes were estimated: the change in level (immediate change), defined as the difference
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