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IIR 20-076 – HSR Study

IIR 20-076
Promoting De-Implementation of Inappropriate Antimicrobial Use in Cardiac Device Procedures By Expanding Audit and Feedback
Westyn Branch-Elliman, MD MS BA
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
Boston, MA
Funding Period: May 2021 - September 2025


Background: Cardiac device procedures, such as pacemaker and defibrillator placements, are common and increasing as the population ages. These devices are life-saving for the Veterans who need them, but the pro- cedures can be complicated by highly morbid infections and other adverse events, resulting in poor outcomes. Clinical guidelines recommend administration of pre-procedural antimicrobials to prevent cardiac device infec- tions and early discontinuation of antimicrobials after the procedure to prevent harms caused by unnecessary antimicrobial use, such as kidney injury, C. difficile infections, and antimicrobial resistance. However, these guidelines are rarely applied, resulting in preventable morbidity and mortality, and creating a critical need for research investigating strategies to promote adoption of best practices (e.g., learning) and de-adoption of inef- fective and harmful practices (e.g., unlearning). Significance/Impact: The research in this study closes an important gap in the care of cardiac device recipients and advances several VA HSR&D research priorities, including implementation, informatics, and quality of care. It leverages the strength of the VA electronic health record (EHR) and will provide important insights into clinical informatics methodologies for expanding surveillance of healthcare-associated infections and antimicrobial use to include outpatient and procedural areas. Investigators will also promote understanding about how learning and unlearning processes can be leveraged to enhance adoption of clinical guidelines and de-implementation of ineffective and harmful practices. Innovation: The highly innovative, informatics-based audit and feedback system will advance the field of imple- mentation science by yielding a new strategy for promoting de-implementation of inappropriate practices. Les- sons learned about how to implement novel, real-time informatics tools and adapt and scale them will also be generalizable to procedural areas with limited resources to support surveillance. Aim I: Tests the hypothesis that a multi-faceted implementation strategy including automated audit and feed- back, education of electrophysiology team members, local adaptation, and blended facilitation with engagement of local champions, will improve adoption of antimicrobial prophylaxis guidelines for electrophysiology proce- dures at three VA facilities, using a stepped-wedge, Hybrid III design. Primary outcome is adoption of guideline- recommended antimicrobial use. Clinical effectiveness will be assessed through measurement of clinical out- comes (CIED infections, AKI, and C. difficile). Aim II: Measures the feasibility of using an informatics-based algorithm to measure outcomes and guideline- concordance following cardiac device procedures at 78 facilities and tests the passive diffusion of reports. Methodology: There is a major gap in studies evaluating de-implementation of ineffective practices. This study has two complimentary aims and will address this gap by testing the utility of a highly innovative clinical infor- matics tool developed using the robust VA EHR. The informatics tool combines feedback about best practices and positive clinical outcomes (learning) with feedback about ineffective and harmful practices and adverse clin- ical outcomes (unlearning) as part of a multi-faceted implementation strategy. Aim I will test the multi-faceted implementation strategy at three VAs using a Hybrid III design. Aim II will test the tool’s scalability and dissemi- nation throughout the VA and will identify barriers to expansion and potential solutions. Implementation/Next Steps: The central aim of this study is to implement ways to promote best practices. Tools developed during the course of the study will be widely disseminated throughout the VA to enhance the quality of care and will be provided to key operational partners, who can adapt the clinical informatics tools to promote best practices in other clinical cares with limited infection prevention and stewardship resources.

External Links for this Project

NIH Reporter

Grant Number: I01HX003234-01

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Journal Articles

  1. Reyes Dassum S, Mull HJ, Golenbock S, Lamkin RP, Epshtein I, Shin MH, Strymish JM, Blumenthal KG, Colborn K, Branch-Elliman W. A Novel Informatics Tool to Detect Periprocedural Antibiotic Allergy Adverse Events for Near Real-time Surveillance to Support Audit and Feedback. JAMA Network Open. 2023 May 1; 6(5):e2313964. [view]
  2. Shenoy ES, Branch-Elliman W. Automating surveillance for healthcare-associated infections: Rationale and current realities (Part I/III). Antimicrobial stewardship & healthcare epidemiology : ASHE. 2023 Feb 10; 3(1):e25. [view]
  3. Branch-Elliman W, Elwy AR, Chambers DA. Embracing dynamic public health policy impacts in infectious diseases responses: leveraging implementation science to improve practice. Frontiers in public health. 2023 Aug 17; 11:1207679. [view]
  4. Al Lawati H, Shin M, Lamkin R, Thompson T, Epshtein I, Mull H, Basnet Thapa D, Drekonja D, Rodriguez-Barradas MC, Xu TH, Gold H, Elwy AR, Strymish J, Branch-Elliman W. Engaging patients in antimicrobial stewardship: co-designed educational tool to improve periprocedural care through de-implementation of guideline-discordant antimicrobial use. Antimicrobial stewardship & healthcare epidemiology : ASHE. 2023 Sep 28; 3(1):e163. [view]
  5. La J, Fillmore NR, Do NV, Brophy M, Monach PA, Branch-Elliman W. Factors associated with the speed and scope of diffusion of COVID-19 therapeutics in a nationwide healthcare setting: a mixed-methods investigation. Health research policy and systems. 2022 Dec 14; 20(1):134. [view]
  6. Branch-Elliman W, Sundermann AJ, Wiens J, Shenoy ES. Leveraging electronic data to expand infection detection beyond traditional settings and definitions (Part II/III). Antimicrobial stewardship & healthcare epidemiology : ASHE. 2023 Feb 10; 3(1):e27. [view]
  7. Branch-Elliman W, Lamkin R, Shin M, Mull HJ, Epshtein I, Golenbock S, Schweizer ML, Colborn K, Rove J, Strymish JM, Drekonja D, Rodriguez-Barradas MC, Xu TH, Elwy AR. Promoting de-implementation of inappropriate antimicrobial use in cardiac device procedures by expanding audit and feedback: protocol for hybrid III type effectiveness/implementation quasi-experimental study. Implementation science : IS. 2022 Jan 29; 17(1):12. [view]
  8. Branch-Elliman W, Sundermann AJ, Wiens J, Shenoy ES. The future of automated infection detection: Innovation to transform practice (Part III/III). Antimicrobial stewardship & healthcare epidemiology : ASHE. 2023 Feb 10; 3(1):e26. [view]

DRA: Cardiovascular Disease, Infectious Diseases
DRE: Treatment - Implementation, TRL - Applied/Translational
Keywords: Best Practices, Guideline Development and Implementation, Surveillance, System Performance Measures
MeSH Terms: None at this time.

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