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IMAGINE - IMproving Adherence to Guidelines in Infectious diseases through Nudging and Education Caris, M.G.
2019
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Martine Caris diseases through IMAGINE Guidelines in Infectious IMproving Adherence to Adherence IMproving Nudging and Education
Martine Caris
diseases through Nudging and Education Nudging diseases through IMAGINE IMproving Adherence to Guidelines in Infectious in Infectious Guidelines to Adherence IMproving
IMproving Adherence to Guidelines in Infectious diseases through Nudging and Education Martine Caris
UITNODIGING
Voor het bijwonen van de openbare verdediging van het proefschrift:
IMAGINE
IMproving Adherence to Guidelines in Infectious diseases through Nudging and Education
Op donderdag 19 september 2019 om 13.45 in de aula van de Vrije Universiteit, de Boelelaan 1105, Amsterdam
Aansluitend bent u van harte welkom op de receptie ter plaatse
Martine Caris Lutmastraat 77-3 1073 GP Amsterdam [email protected] 06-21907756
Paranimfen Koen van Beers [email protected] 06-11241753
Wessel Fuijkschot [email protected] 06-40102292 IMAGINE IMproving Adherence to Guidelines in Infectious diseases through Nudging and Education
Martine Caris IMproving Adherence to Guidelines in Infectious diseases through Nudging and Education
ISBN 9789463237246 Author Martine G. Caris Cover Stephanie Nanninga by Studio Marieke Wisse Layout and printing Gildeprint Drukkerijen, Enschede
© M.G. Caris, Amsterdam, The Netherlands, 2019 All rights reserved. No part of this thesis may be reproduced, stored, or transmitted in any form or by any means, without prior permission of the author.
Financial support by Amsterdam UMC, location VUmc, Amsterdam, The Netherlands, for the work within this thesis is gratefully acknowledged.
The printing of this thesis was additionally kindly supported by the Nederlandse Vereniging voor Medisch Onderwijs, Ophardt Hygiene-Technik GmbH + Co. KG, ChipSoft and the department of Internal medicine of Amsterdam UMC, location VUmc. VRIJE UNIVERSITEIT
IMAGINE
IMproving Adherence to Guidelines in Infectious diseases through Nudging and Education
ACADEMISCH PROEFSCHRIFT
ter verkrijging van de graad Doctor aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. V. Subramaniam, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de Faculteit der Geneeskunde op donderdag 19 september 2019 om 13.45 uur in de aula van de universiteit, De Boelelaan 1105
door
Martine Gertrude Caris
geboren te Utrecht promotoren: prof.dr. C.M.J.E. Vandenbroucke-Grauls prof.dr. M.H.H. Kramer copromotor: prof.dr. M.A. van Agtmael leescommissie: Prof.dr. C. Boer Prof.dr. A. Voss Prof.dr. J.M. Prins Prof.dr. M.C. Vos Prof.dr. M.E. Hulscher dr. J. ten Oever paranimfen: dr. C.A.J. van Beers dr. W.W. Fuijkschot
Voor mijn ouders CONTENTS
CHAPTER 1 Introduction and outline of this thesis 11
PART I – INFECTION CONTROL
CHAPTER 2 Patient safety culture and the ability to improve: a proof of 23 concept study on hand hygiene
CHAPTER 3 Effectiveness of a behavioural approach to healthcare 45 worker compliance with hospital dress code CHAPTER 4 Nudging to improve hand hygiene 61
PART II – EDUCATION ON ANTIBIOTIC PRESCRIBING
CHAPTER 5 Improving antibiotic prescribing skills in medical students: 77 the effect of e-learning after six months
CHAPTER 6 E-learning on antibiotic prescribing – the role of 91 autonomous motivation in participation: a prospective cohort study
CHAPTER 7 Important aspects of effective e-learning: the right 103 timing and appropriate behavioural interventions to educate junior doctors on antibiotic prescribing and infection control
PART III – ANTIBIOTIC STEWARDSHIP AND INFECTION CONTROL IN GUIDELINES
CHAPTER 8 Adapting empiric antibiotic treatment for suspected 115 bloodstream infection to increasing Gram-negative resistance
CHAPTER 9 Indwelling time of peripherally inserted central catheters 133 and incidence of bloodstream infections in haematology patients: a cohort study
147 CHAPTER 10 Summary of main findings, general discussion and future directions 162 CHAPTER 11 Publications 163 Dankwoord Acknowledgements 168 Biografie Biography People don’t realize that the future is just now, but later - Russell Brand 1
CHAPTER 1 Introduction and outline of this thesis INTRODUCTION
The increasing resistance of microorganisms to antimicrobials poses a serious and ever-growing threat to patients all around the world. Formerly susceptible bacteria are developing more and more defence mechanisms against our antibiotics. Combined with the stagnant development of new antimicrobials, this means the precious antimicrobial arsenal of modern day healthcare is declining every day. 1
Whereas the right to prescribe antipsychotics or chemotherapeutic agents is generally limited to well-trained specialists, virtually all doctors are allowed to prescribe antibiotics, regardless of specialty, experience, or knowledge. 2,3 This is reflected in the number of unjustified antibiotic prescriptions: misuse of antimicrobials, be it unnecessary, inappropriate, or both, can be found in up to a staggering fifty percent of prescriptions.4-9
Closely related to the problem of antibiotic resistance is the threat of healthcare- associated infections (HAIs). HAIs are the most common adverse events in the healthcare setting, representing the fifth leading cause of death in hospitalized patients. 10,11 HAIs are associated with increased morbidity, hospital length-of-stay, and costs, and their incidence is increasing.11-14 In addition, in line with the rising antimicrobial resistance, an increasing proportion of these HAIs is caused by multidrug-resistant organisms, which are more difficult to treat.15,16 To prevent dissemination of pathogens and consequently prevent HAIs, proper infection control is paramount. Hand hygiene in particular has proven important in preventing healthcare-associated infections.17,18 Compliance with infection control measures, however, is known to be poor. 19
The rise in antibiotic resistance has led to the adoption of antimicrobial stewardship programs (ASPs),20 which have been mandatory for hospitals in the Netherlands since 2014. As the magnitude of resistance has been extensively linked to the quantity and quality of antimicrobial prescribing,21-24 ASPs focus on improving antimicrobial prescribing, with the aim of optimizing patient outcomes, reducing costs and adverse effects, and ultimately reducing antimicrobial resistance.25,26 Most ASP’s, however, seem to overlook a very important aspect of the antimicrobial resistance problem: by preventing infections, one also reduces the need for antimicrobial therapy, thus lowering the burden of antibiotics. Yet most ASPs do not incorporate measures to improve infection control. This evident connection between antimicrobial stewardship and infection control should be utilised. As both require behaviour change, they can
Chapter 1 benefit from interventions based on the same concepts and principles. The key lies in 12 combining efforts to improve antimicrobial prescribing and infection control. Guideline adherence and behaviour change In both antimicrobial stewardship and infection prevention measures, the aim is to improve guideline adherence (also referred to as compliance). Although many 1 methods have been applied,27 structural improvement has proven challenging and interventions rarely have long-term effects. 19,28-34 It is increasingly recognized that improving guideline adherence requires behaviour change, and to achieve this, insight is needed into the interaction between individuals, their peers, and the working environment. Promising approaches, not yet commonly applied in healthcare, are methods based on decision-making processes, such as participatory action research (PAR), nominal group technique (NGT) and root cause analysis (RCA). These methods focus on collaboration with and empowerment of the stakeholders, and are all based on their close involvement in the process of change. 35-37 Another potentially useful method to achieve behaviour change is nudging: a friendly push to encourage desired behaviour. Nudging is widely used to stimulate healthy behaviour, such as smoking cessation and healthy food choices, for example in cafetaria, through positioning ‘healthier’ foods at eye level. 38-40 Nudging of healthcare workers has recently been addressed in a few studies, in which various kinds of nudges proved successful in influencing physician prescribing behaviour.41-44
In recent years, there has also been an increasing interest in the influence of safety culture on (hospital) performance, specifically in guideline adherence and infection control.45,46 Treatment and prevention of infections play a major role in patient safety, and patient safety in itself is considered a fundamental aspect of organizational culture. Although establishing culture change is challenging, it has been suggested that strategies focused on organisational change could positively influence performance outcomes, specifically in infection control. 45-47
Junior doctors Another possible blind spot of current hospital antimicrobial stewardship programs (ASPs) is that many of the interventions are aimed at staff members, whereas junior doctors mainly fulfil the role of ward physician. They are responsible for the majority of antibiotic prescriptions and play an essential role in preventing healthcare-associated infections (HAIs) through adequate infection control measures. These responsibilities are to be met during a stressful transitional period from student to physician, or from research to clinical work, during which junior doctors perceive a lack of knowledge and skills, specifically in prescribing medication.48-50 Medical training does not target many of the practical skills needed in the hospital setting and pharmacotherapy education is mostly aimed at general practice.51 Education at commencement of work, aimed at practicing guideline-based medicine in busy daily practice, could facilitate this transition. 13 E-learning Although education is considered a cornerstone of antimicrobial stewardship, resources are limited. Stewardship programs therefore increasingly rely on e-learning as an educational method.52,53 The advantages of e-learning are legion: it provides flexibility, allows interactivity and progress tracking, and after initial development, modules are easily distributed among large groups and across the globe, against relatively small investments of time and costs. 54,55 E-learning is considered an effective educational method for medical students and nurses and can increase prescribing skills.56-62 However, it is not known whether e-learning during a short period of time can improve antimicrobial prescribing behaviour in the long term. 55,59,60 In addition, e-learning requires a lot of motivation, as it is usually non-obligatory and performed individually. To fully benefit from e-learning as an intervention in stewardship, more insight is needed into its merits and into ways to maximize its effect.
Guidelines Finally, in order to reduce antimicrobial resistance and HAIs by enhancing guideline adherence, the guidelines themselves should be designed according to stewardship and infection control standards. We aim to increase guideline adherence through behavioural interventions, but how ‘stewardship’ are commonly used guidelines?
OUTLINE OF THIS THESIS
The work presented in this thesis was inspired by the belief that antimicrobial stewardship and infection control are intertwined themes that can benefit from the same interventions. The aim of this thesis, therefore, was to study new ways to improve both infection prevention and antimicrobial stewardship, by focusing on behaviour and learning, and the role of guidelines. These subjects are addressed in the following three parts: in PART I we focused on the merits of behavioural interventions to improve guideline adherence in infection control. Chapter 2 describes a qualitative exploration of safety culture in hospital units, following a before-and-after trial on hand hygiene. In chapter 3, we investigated whether applying decision-making methods can increase compliance with hospital dress code. Chapter 4 provides an overview of the existing literature on nudging describes how we developed nudges for hand hygiene and investigated whether these could increase the use of alcohol- based hand rub. PART II consists of three chapters on the role of e-learning: we performed a prospective controlled intervention study to assess whether e-learning
Chapter 1 can improve medical students’ antibiotic prescribing skills later on ( chapter 5), and 14 investigated the role of intrinsic motivation in residents’ participation in e-learning (chapter 6). In chapter 7, we illustrate how we developed an online course on antimicrobial stewardship and infection control for junior doctors, with input from their peers. PART III describes two multicentre, retrospective cohort studies in 1 which we reviewed guidelines for two common situations in the hospital: antibiotic therapy in patients suspected of bloodstream infection ( chapter 8) and management of a frequently used intravenous line in patients with haematological malignancies (chapter 9). Finally, chapter 10 presents a summary and general discussion, and considers possible implications of our results for the future.
15 REFERENCES
1 Antibiotic resistance: long-term solutions require action now. Lancet Infect Dis 2013; 13: 995. 2 Abbo LM, Cosgrove SE, Pottinger PS et al. Medical students’ perceptions and knowledge about antimicrobial stewardship: how are we educating our future prescribers? Clin Infect Dis 2013; 57: 631-8. 3 Lee CR, Cho IH, Jeong BC, Lee SH. Strategies to minimize antibiotic resistance. Int J Environ Res Public Health 2013; 10: 4274-305. 4 Dyar OJ, Howard P, Nathwani D, Pulcini C. Knowledge, attitudes, and beliefs of French medical students about antibiotic prescribing and resistance. Med Mal Infect 2013; 43: 423-30. 5 Huijts SM, Van Werkhoven CH, Boersma WG et al. Guideline adherence for empirical treatment of pneumonia and patient outcome. Treating pneumonia in the Netherlands. Neth J Med 2013; 71: 502-7. 6 Pulcini C, Gyssens IC. How to educate prescribers in antimicrobial stewardship practices. Virulence 2013; 4: 192-202. 7 Spoorenberg V, Hulscher ME, Akkermans RP, Prins JM, Geerlings SE. Appropriate antibiotic use for patients with urinary tract infections reduces length of hospital stay. Clin Infect Dis 2014; 58: 164-9. 8 Srinivasan A, Song X, Richards A, Sinkowitz-Cochran R, Cardo D, Rand C. A survey of knowledge, attitudes, and beliefs of house staff physicians from various specialties concerning antimicrobial use and resistance. Arch Intern Med 2004; 164: 1451-6. 9 Pulcini C, Cua E, Lieutier F, Landraud L, Dellamonica P, Roger PM. Antibiotic misuse: a prospective clinical audit in a French university hospital. European Journal of Clinical Microbiology & Infectious Diseases 2007; 26: 277-80. 10 Sydnor ER, Perl TM. Hospital epidemiology and infection control in acute-care settings. Clin Microbiol Rev 2011; 24: 141-73. 11 Organization WH. Report on the Burden of Endemic Health Care-Associated Infection Worldwide. Geneva2011. 12 Burke JP. Infection control - a problem for patient safety. N Engl J Med 2003; 348: 651-6. 13 De Kraker ME, Davey PG, Grundmann H. Mortality and hospital stay associated with resistant Staphylococcus aureus and Escherichia coli bacteremia: estimating the burden of antibiotic resistance in Europe. PLoS Med 2011; 8: e1001104. 14 Stone PW. Economic burden of healthcare-associated infections: an American perspective. Expert Rev Pharmacoecon Outcomes Res 2009; 9: 417-22. 15 Aboelela SW, Stone PW, Larson EL. Effectiveness of bundled behavioural interventions to control healthcare-associated infections: a systematic review of the literature. J Hosp Infect 2007; 66: 101-8. 16 Cosgrove SE. The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. Clin Infect Dis 2006; 42 Suppl 2: S82-9. 17 Little P, Stuart B, Hobbs FDR et al. An internet-delivered handwashing intervention to modify influenza- like illness and respiratory infection transmission (PRIMIT): a primary care randomised trial. The Lancet 2015; 386: 1631-9. 18 Pittet D, Hugonnet S, Harbarth S et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000; 356: 1307-12. 19 Huis A, Holleman G, Van Achterberg T, Grol R, Schoonhoven L, Hulscher M. Explaining the effects of two different strategies for promoting hand hygiene in hospital nurses: a process evaluation alongside a cluster randomised controlled trial. Implement Sci 2013; 8: 41. 20 Dellit TH, Owens RC, Mcgowan JE, Jr. et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44: 159-77. 21 Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient antibiotic use in Europe and association Chapter 1 with resistance: a cross-national database study. Lancet 2005; 365: 579-87. 16 22 May AK, Melton SM, Mcgwin G, Cross JM, Moser SA, Rue LW. Reduction of vancomycin-resistant enterococcal infections by limitation of broad-spectrum cephalosporin use in a trauma and burn intensive care unit. Shock 2000; 14: 259-64. 1 23 Seppala H, Klaukka T, Vuopio-Varkila J et al. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. Finnish Study Group for Antimicrobial Resistance. N Engl J Med 1997; 337: 441-6. 24 White AC, Jr., Atmar RL, Wilson J, Cate TR, Stager CE, Greenberg SB. Effects of requiring prior authorization for selected antimicrobials: expenditures, susceptibilities, and clinical outcomes. Clin Infect Dis 1997; 25: 230-9. 25 Macdougall C, Polk RE. Antimicrobial stewardship programs in health care systems. Clin Microbiol Rev 2005; 18. 26 Owens RC, Jr. Antimicrobial stewardship: concepts and strategies in the 21st century. Diagn Microbiol Infect Dis 2008; 61: 110-28. 27 Davey P, Marwick CA, Scott CL et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017; 2: CD003543. 28 Al-Tawfiq JA, Pittet D. Improving hand hygiene compliance in healthcare settings using behavior change theories: reflections.Teach Learn Med 2013; 25: 374-82. 29 Erasmus V, Brouwer W, Van Beeck EF et al. A qualitative exploration of reasons for poor hand hygiene among hospital workers: lack of positive role models and of convincing evidence that hand hygiene prevents cross-infection. Infect Control Hosp Epidemiol 2009; 30: 415-9. 30 Erasmus V, Daha TJ, Brug H et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010; 31: 283-94. 31 Erasmus V, Huis A, Oenema A et al. The ACCOMPLISH study. A cluster randomised trial on the cost- effectiveness of a multicomponent intervention to improve hand hygiene compliance and reduce healthcare associated infections. BMC Public Health 2011; 11: 721. 32 Huis A, Schoonhoven L, Grol R et al. Helping hands: a cluster randomised trial to evaluate the effectiveness of two different strategies for promoting hand hygiene in hospital nurses.Implement Sci 2011; 6: 101. 33 Huis A, Van Achterberg T, De Bruin M, Grol R, Schoonhoven L, Hulscher M. A systematic review of hand hygiene improvement strategies: a behavioural approach. Implement Sci 2012; 7: 92. 34 Tromp M, Huis A, De Guchteneire I et al. The short-term and long-term effectiveness of a multidisciplinary hand hygiene improvement program. Am J Infect Control 2012; 40: 732-6. 35 Van Buul LW, Sikkens JJ, Van Agtmael MA, Kramer MH, Van Der Steen JT, Hertogh CM. Participatory action research in antimicrobial stewardship: a novel approach to improving antimicrobial prescribing in hospitals and long-term care facilities. J Antimicrob Chemother 2014; 69: 1734-41. 36 Sikkens JJ, Van Agtmael MA, Peters EJG et al. Behavioral Approach to Appropriate Antimicrobial Prescribing in Hospitals: The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) Participatory Intervention Study. JAMA Intern Med 2017. 37 Carney O, Mcintosh J, Worth A. The use of the Nominal Group Technique in research with community nurses. J Adv Nurs 1996; 23: 1024-9. 38 Kroese FM, Marchiori DR, De Ridder DT. Nudging healthy food choices: a field experiment at the train station. J Public Health (Oxf) 2016; 38: e133-7. 39 Sunstein CR. Nudging smokers. N Engl J Med 2015; 372: 2150-1. 40 Wilson AL, Bogomolova S, Buckley JD. Lack of efficacy of a salience nudge for substituting selection of lower-calorie for higher-calorie milk in the work place. Nutrients 2015; 7: 4336-44. 41 Meeker D, Knight TK, Friedberg MW et al. Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA Intern Med 2014; 174: 425-31. 42 Katchanov J, Kluge S, Mackenzie CR, Kaasch AJ. “Nudging” in microbiological reports: a strategy to improve prescribing. Infection 2016. 17 43 Bourdeaux CP, Davies KJ, Thomas MJ, Bewley JS, Gould TH. Using ‘nudge’ principles for order set design: a before and after evaluation of an electronic prescribing template in critical care. BMJ Qual Saf 2014; 23: 382-8. 44 Tannenbaum D, Doctor JN, Persell SD et al. Nudging physician prescription decisions by partitioning the order set: results of a vignette-based study. J Gen Intern Med 2015; 30: 298-304. 45 De Bono S, Heling G, Borg MA. Organizational culture and its implications for infection prevention and control in healthcare institutions. J Hosp Infect 2014; 86: 1-6. 46 Dodek P, Cahill NE, Heyland DK. The relationship between organizational culture and implementation of clinical practice guidelines: a narrative review. JPEN J Parenter Enteral Nutr 2010; 34: 669-74. 47 Smiddy MP, R OC, Creedon SA. Systematic qualitative literature review of health care workers’ compliance with hand hygiene guidelines. Am J Infect Control 2015; 43: 269-74. 48 Alexander C, Millar J, Szmidt N, Hanlon K, Cleland J. Can new doctors be prepared for practice? A review. Clin Teach 2014; 11: 188-92. 49 Illing JC, Morrow GM, Rothwell Nee Kergon CR et al. Perceptions of UK medical graduates’ preparedness for practice: a multi-centre qualitative study reflecting the importance of learning on the job.BMC Med Educ 2013; 13: 34. 50 Teunissen PW, Westerman M. Junior doctors caught in the clash: the transition from learning to working explored. Med Educ 2011; 45: 968-70. 51 Vollebregt JA, Van Oldenrijk J, Kox D et al. Evaluation of a pharmacotherapy context-learning programme for preclinical medical students. Br J Clin Pharmacol 2006; 62: 666-72. 52 Nathwani D, Guise T, Gilchrist M. e-learning for global antimicrobial stewardship. The Lancet Infectious Diseases 2017; 17: 579. 53 Robilotti E, Holubar M, Nahrgang S, Van De Sande-Bruinsma N, Lo Fo Wong D, Deresinski S. Educating front-line clinicians about antimicrobial resistance. The Lancet Infectious Diseases 2017; 17: 257-8. 54 Gordon M, Chandratilake M, Baker P. Low fidelity, high quality: a model for e-learning. Clin Teach 2013; 10: 258-63. 55 Rocha-Pereira N, Lafferty N, Nathwani D. Educating healthcare professionals in antimicrobial stewardship: can online-learning solutions help? J Antimicrob Chemother 2015; 70: 3175-7. 56 Feng JY, Chang YT, Chang HY, Erdley WS, Lin CH, Chang YJ. Systematic review of effectiveness of situated e-learning on medical and nursing education. Worldviews Evid Based Nurs 2013; 10: 174-83. 57 Lee TY, Lin FY. The effectiveness of an e-learning program on pediatric medication safety for undergraduate students: a pretest-post-test intervention study. Nurse Educ Today 2013; 33: 378-83. 58 Gaikwad N, Tankhiwale S. Interactive E-learning module in pharmacology: a pilot project at a rural medical college in India. Perspect Med Educ 2014; 3: 15-30. 59 Gordon M, Chandratilake M, Baker P. Improved junior paediatric prescribing skills after a short e-learning intervention: a randomised controlled trial. Arch Dis Child 2011; 96: 1191-4. 60 Maxwell S, Mucklow J. e-Learning initiatives to support prescribing. Br J Clin Pharmacol 2012; 74: 621-31. 61 Ruggeri K, Farrington C, Brayne C. A global model for effective use and evaluation of e-learning in health. Telemed J E Health 2013; 19: 312-21. 62 Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-learning in medical education. Acad Med 2006; 81: 207- 12.
Chapter 1 18
1
19
INFECTION CONTROL Culture eats strategy for breakfast - Peter Drucker 2 CHAPTER 2 Patient safety culture and the ability to improve: a proof of concept study on hand hygiene
Martine G. Caris Pim G.A. Kamphuis Mireille Dekker Martine C. de Bruijne Michiel A. van Agtmael Christina M.J.E. Vandenbroucke-Grauls
Infection Control and Hospital Epidemiology, November 2017 24 Chapter 2 aid improvement andprevent non-productive interventions. could interventions implementing before culture safety the Strengthening asteam-building exercises. such strategies enhancement from benefit can unit a on culture culture. Although safety additional of research levels is needed low to corroboratewith our units findings,in the safety applied when effective be not may Interventions CONCLUSIONS low-performing unitsshowedlowlevelsofsafetyculture. while culture, safety of levels high showed units high-performing results, interview and compliance comparing When cultures. safety pathological or bureaucratic had RESULTS level). (highest generative as or proactive, categorized bureaucratic, reactive, was level), (lowest culture pathological Safety Culture. Safety on Patient based on Survey nurses, Hospital and the physicians, management, unit with interviews conducted improvement no and were selected as low showed performing. A blinded, independent observer units 2 Another performing. high as and selected were (21% respectively) improvement 16%, significant showed that units 2 and compliance hygiene hand highest the with unit hospital the approach: deviance positive a We using culture interventions. after times 4 safetyevaluate to units selected and baseline, from compliance in and changes analysed before, twice measured observation, was compliance direct years, through 2 Over compliance. improve to program wide METHODS SETTING before-and-after trialonhandhygiene. DESIGN with theabilitytoimprove. OBJECTIVE ABSTRACT ulttv ivsiain f aey utr o hsia uis olwn a following units hospital on culture safety of investigation Qualitative VUUniversityMedicalCenter, atertiary-care hospitalintheNetherlands. Overall, 3 units showed a proactive or generative safety culture and 2 units With support from hospital management, we implemented a hospital- a implemented we management, hospital from support With To culturesafety the whether investigate associated is unit hospital a of Safety culture is associated with the ability to improve hand hygiene. INTRODUCTION
In recent years, interest in the influence of hospital safety culture on professional performance has grown, specifically with regard to guideline adherence 1 and infection control.2 In infection control, hand hygiene has proven particularly important. 3 Large 2 interventional studies have shown that increases in hand hygiene compliance can decrease nosocomial infection rates.4,5 Still, adherence to hand hygiene guidelines is notoriously poor.6
Many methods have been applied to enhance hand hygiene compliance, 7 but achieving structural improvement is challenging, and interventions rarely have long- term effects.8,9 In addition, newly developed interventions are typically less successful when applied in other hospitals. 10 Although differences in organizational factors may play a role, failure to implement previously successful interventions is often attributed to differences in hospital culture.
Not only is there great variation in hand hygiene compliance among hospitals, 11 differences are also observed among units of the same hospital. 12-14 As hospital units often work with designated teams and care for a specific patient population, this intra-hospital variation could be attributed to differences in the safety culture at the unit level. Although changing the safety culture is challenging, it has been suggested that improving the safety culture could positively influence outcomes, 1,2 and interventions to change the organizational safety culture have been shown to improve infection control.15,16
The relationship between patient safety culture and the ability to improve has not yet been clearly defined, but it could provide insight on how efforts to increase hand hygiene compliance, or guideline adherence in general, can be optimized. In our hospital, we assessed the effects of a 2-year, institution-wide hand hygiene improvement program, and we observed large differences among hospital units. We investigated the patient safety culture on these units and assessed the relationship between the level of safety culture and the ability to improve hand hygiene compliance.
25 26 Chapter 2 as A iiu o 2 bevr cletd aa o a lat 4 hn hygiene hand 140 least at for data opportunities, perunit,measurement, asproposed collected bytheWHO. observers 2 of minimum A days. Five Moments WHO of Hand Hygiene. the on based application an Lite, iScrub in registered were and covert, not but discrete, and unannounced were Observations Films. Training and Manual TechnicalReference Hygiene Hand WHO’s the to according trained were Observers Data collection performed 2baselinemeasurements and4postinterventionmeasurements. and non-intensive care units, paediatric and adult patient wards). On these units, we unitscare intensive units, nonsurgical and surgical (i.e., hospital the of cross-section a represented units these monitoring; closer for and units 2014 8 selected January We 2016. between March units all on compliance hygiene hand measured We Study population Hand Hygiene installed dispensersontheendsofallhospitalbedstoenhanceavailability. tests to select the alcohol-based hand rub that healthcare workers preferred, and we pilot conducted additionally We experience. might unit the problems any including discuss these results with the staff. Possible explanations for findings were addressed, presented with compliance results after every measurement and were encouraged to using Toolkit interventions they considered useful for their team. Unit managers were improvement,for action of plan a devise to them encouraged and managers unit to received feedback on baseline compliance. Hospital management then sent the online). ToolkitMaterial Supplementary the (see interventions effective of review literature extensive an after Toolkit,” for Improvement Hygiene “Hand a compiled We requisites and their own infrastructureimprovements. Hospital management declared hand hygiene a top forpriority. responsible be to upon the called were units hospital individual and improvement, provided Several interventions project. improvement hygiene hospital-wide hand extensive an launched we 2014, In over 2years,andweassessedsafetyculture through semi-structured compliance interviews. in changes evaluated we interventions; after and before unit hospital each investigationin compliance hygiene hand qualitative observed study.We before-and-after a a following performing by study mixed-methods a conducted We Study design METHODS 17 Measurements took place on at least 2 non-consecutive 18
9 All units All Statistical analysis We calculated compliance using the sum of all observed opportunities in which hand hygiene was performed divided by the sum of all observed opportunities in which hand hygiene was indicated. We assessed changes in compliance through longitudinal logistic regression analyses; we corrected for correlated observations 2 through stratification per unit and by adding a time-dependent covariate.
Interviews Study population 5 hospital units were selected to investigate the relationship between safety culture and the ability to improve. We used the positive deviance approach, which identifies behaviour that enables groups or individuals to outperform their peers. 19 We defined positive deviance as the ability to improve hand hygiene compliance during the intervention period and selected the 2 best performing and 2 least performing units. A fifth unit that did not improve, but consistently showed the hospital’s highest compliance, was also included as high performing. With purposeful sampling, we selected interviewees from each unit, to encompass both managers’ and non-managers’ perspectives, and both medical and nursing points of view: the management (medical director and nurse manager), 2 doctors and 2 nurses, until data saturation. Interviewees had to have been employed for at least 24 months to ensure both pre- and post-intervention experiences.
Data collection The interview guide consisted of open-ended questions based on COMPaZ, the validated Dutch version of the Hospital Survey on Patient Safety Culture. 20 To fit our study, some adaptations were made. (The interview guide, COMPaZ description, and adaptations are provided in the Supplementary Material online.) An independent, experienced observer (P.K.) conducted semi structured interviews from May through July 2016. To prevent bias, he had no knowledge of each hospital unit’s compliance prior to the interviews.
Analysis Interviews were transcribed verbatim. Analysis followed 3 steps: (1) Open coding was conducted to name and categorize phenomena and to ensure data completeness; (2) with axial coding, connections were drawn between answers; and (3) selective coding further refined answers while linking them to the dimensions of patient safety culture. Quotes that exemplified responses from the same unit were selected to illustrate meaning. The coding frame was developed iteratively as 2 researchers (M.C. and P.K.) read the transcripts. To prevent bias in the coding frame, P.K. was still 27 28 Chapter 2 Assessment Framework 1 TABLE of safety culture toeachunit. level overall an assign to calculated 5 was to score summary 1 A respectively. receiving points, generative, or proactive bureaucratic, reactive, pathological, as culture. safety assess to framework to assess way the level of safety valid culture: individual responses were a categorized as WHO the by listed is and proposed (MaPSaF) 1), (Table Framework adaptations. levels 5 in Assessment maturity culture safety Safety of categorization Patient Manchester The coding frame were needed. the in adjustments whether evaluated regularly we drift, coder Toavoid transcripts. the coding structure. We then proceeded with a single coder (P.K.) for the remaining to these codes. After double-coding 5 transcripts, we discussed findings and defined allocatedwere transcripts the from Excerpts participants. by raised topics and guide interview the by covered were that topics both noted, were themes Recurrent unit. respondent’s the to blinded was M.C. and performance, hygiene hand to blinded Pathological Reactive Bureaucratic Proactive Generative Level Culture ofSafety Categorization of safety culture in five levels, proposed by the Manchester Patient Safety Patient the Manchester by proposed levels, five in culture safety of Categorization 22,23 The MaPSaF method has been adapted for all healthcare settings healthcare all for adapted been has method MaPSaF The 21 Why dowe needto waste ourtimeonpatient issues? safety We take patient seriouslyanddosomethingwhenwe safety have anincident We have systems inplace to managepatient safety We are about patient always issuesthat safety might onthealert/thinking emerge weManaging patient ofeverything do isanintegral safety part Description 21 ae o earlier on based 24 e sd this used We RESULTS
Hand Hygiene We observed 6,401 hand hygiene opportunities in 8 hospital units (Figure 1). Mean baseline compliance was 46% (range, 33%–74%). Units 1 and 4 showed the largest 2 improvements (21% and 16%, respectively). Unit 2 consistently showed the hospital’s highest compliance (74%). These 3 units were selected as high performing. Units 3, 6, and 7 showed no changes from baseline. During interventions, unit 7 underwent reorganization and was excluded because such changes can affect safety culture and can confound findings. We selected units 3 and 6 as low performing.
FIGURE 1 Hand hygiene compliance per unit, per measurement. First bar represents pooled baseline compliance, other bars represent measurements during the intervention period. Δ, change from baseline; OR, odds ratio; CI, confidence interval
Safety Culture We interviewed 24 respondents, 4 on unit 3, and 5 on all other units (see Distribution in the Supplementary Material online). Table 2 shows unit characteristics. High- performing units showed high levels of safety culture, while low-performing units showed low levels. The most striking differences were found in the dimensions described in the following section (full description is provided in the supplementary material, additional quotes are available online). 29 30 Chapter 2 and showedaclearconsistentattitudetoward patient safety. noncompliance of consequences the of aware were staff units, high-performing On Overall Perception ofSafety to obstacle an not was hierarchy collaboration, whilenursingstaffexpressed contrasting existing opinions. that mentioned managers and staff Medical collaboration. on view of points opposing showed units Low-performing to improve. effortscollective resultingin involvement, staff with standards,but the set 4 unit on unit management. Units 1 and 2 considered their unit free of hierarchy. The managers of involvement and collaboration close reported consistently units High-performing Teamwork andHierarchy interval; ICU, intensivecare unit TABLE 2 Low-performing Low-performing High-performing High-performing High-performing Criteria Selection “Hierarchy is almost non-existent. There are just differences in responsibilities.” is anintegral part of yourwork.”(doctorHU4) are doing projects on medication safety and prescribing errors. [Hand hygiene] We […] safety. and quality on vision clear a has manager] department “[The that canbedifficultsometimes.”(nurseHU3) And ignored. is Which does. still and opinion, clear a had team [nursing] the “There […] is some discontent. […] projects that were forced through, of which (doctor HU2) Characteristics of Selected Hospital Units. Δ, change from baseline; OR, odds ratio; CI, confidence Pathological Bureaucratic Proactive Proactive, generative Proactive, generative Level Culture ofSafety 56 33 33 34 74 Baseline, % Hand Hygiene Compliance - 9 + 6 +16 +21 - 1 Δ, % 0.69 (0.45-1.06) 1.29 (0.84-2.00) 1.97 (1.28-3.03) 2.40 (1.58-3.66) 0,97(0,61-1,54) OR (95%CI) No No No Yes Yes ICU 2 surgical 1 surgical 1 medical, 1 surgical 1 medical, 1 medical 1 medical Specialties 4 4 9 8 6 Interventions On these units, safety issues were anticipated and efforts were made to improve patient safety in general, while low-performing units described more reactive or even pathological approaches.
“We try to, well, keep an eye on the aspects of patient safety, assessment of 2 scores, fall risk, things like that […]. We try to do, what we can, to monitor patient safety, but things can go wrong, also in our unit.” (medical director HU3)
“[Other units] all stick to the rules, while we have a tendency to work around them. Or deviate from them.” (nurse HU6)
Addressing Non-compliance Addressing co-workers in cases of noncompliance was common on high-performing units. On low-performing units, this was not the case; staff were mainly focused on their own performance.
“I always do that. […] that’s just common practice for the unit.” (doctor HU4)
“[…] with co-workers, I don’t really pay attention. It’s not on me. I have enough on my plate.” (nurse HU6)
Feedback and Improvement Participation in hand hygiene improvement interventions was obligatory on high- performing units, closely involving staff and managers.
“Everyone had to pass the test [on hand hygiene technique] and everyone did, it received a lot of attention, also from [unit] management, I think that’s important.”(nurse HU2)
Low-performing units showed discrepancies in their views on improvement strategies. On unit 3, the nurse manager was scarcely aware of interventions, while staff specifically mentioned measures that had created more awareness. In contrast, the nurse manager of unit 6 mentioned many interventions that were not recognized by staff.
Combining Specialties Although it was not part of the interview guide, collaboration with different specialties on 1 unit emerged as an important factor. Nursing staff on these wards consistently 31 32 Chapter 2 Of the 2 other high-performing units, one unit does not provide intensive care and care intensive provide not does unit one units, high-performing other 2 the Of unit.care critical paediatric the on observed was hospital our in compliance of level compliance, of levels patients. of vulnerability perceived the interventions. of success the impact may that hospitals between culture in differences observed have researchers Several improve. to hard notoriously and poor is compliance infections, Although hand hygiene is the most effective strategy to prevent healthcare-associated are more opentointerventionsimprove performance. units more easily accept new ideas collaborative more and hierarchical less that showing studies with line This in is each). finding interventions (4 units low-performing than interventions) 9 and 8, (6, Although a minor finding, high-performing units had implemented more interventions forms thebasisofTeamSTEPPS approach tosafetyandquality. performance improves safety leadership thateffective showing studies byearlier supported is finding This improvement. to barrier a be to appeared and unit the in culture safety the on impactin an had difficulties clearly factor This showed staff. nursing and consistently caredmedical between collaboration specialties that medical different units 2 Interestingly, of compliance. patients for improve to support and resources, These differences were striking because all units had enjoyed the same opportunities, units withlowerlevelsofsafetyculture didnot. culturesafety of whilelevels improvementcompliance, showed baseline high had or high with Units in units. low-performing and differences high-performing between largeculture safety observed We program. improvement hospital-wide a during We assessed the ability of individual hospital units to improve hand hygiene compliance DISCUSSION Measures takentoalignthespecialtiesdidnotseem tohaveaneffect. specialties. 2 the of staff medical the with communication in differences described HU3) (nurse communicating.” of way own their […] have and fields different in are “So the logistics are different. That can be difficult. To work with. […] They just 12,29,30 22 n ta ta tann cn eue ugcl mortality surgical reduce can training team that and 13 It has been suggested that hand hygiene compliance reflects compliance hygiene hand that suggested been has It which could reflect their overall safety culture. The highest The culture. safety overall their reflect could which 28 and that units with higher levels of safety culture 12 rtcl adarc ae nt hv higher have units care paediatric Critical 23
27
25,26 and the other unit does; however, their baseline compliance was low. In addition, while the 2 low-performing units both care for vulnerable patients, this did not affect either safety culture or compliance. This finding strengthens the idea that safety culture influences the ability to improve more than absolute hand hygiene compliance. 2 The idea that culture influences performance is not a new concept. Earlier publications have clearly demonstrated the importance of organizational culture in improving adherence to infection control measures 16,30 and correlations between unit culture and successful practice have been observed. 22,28 However, most studies focus on changing culture at the hospital level, with huge numbers of employees (>20,000) undergoing safety culture training,31 presumably against considerable cost and time investments. A few intervention studies have shown that changing (elements of) hospital or unit culture can enhance adherence to infection control measures. 15,31-33 However, safety culture is usually not measured at the unit level, 12,29,30,34 and simplistic correlations such as ‘a strong culture leads to good performance’ have not been scientifically supported.2
Our study has strengths and limitations. The use of a hand hygiene observation tool with clearly defined standard operating procedures adds to the value of our findings. Observations were unannounced and discrete, but not covert. Overestimation of absolute compliance rates is probable, 6 as individuals tend to modify their behaviour when they become aware of being observed (ie, the “Hawthorne effect”). 35 With ongoing interventions, the Hawthorne effect may have had greater influence over the course of our study. However, instead of absolute compliance, we used changes in compliance, which do not rely on validity but on responsiveness of the measurement tool. Still, the Hawthorne effect should be taken into account when interpreting these findings. We defined “high performing” as the hospital’s highest compliance or showing the greatest improvement in compliance. Still, our high-performing units showed 49%–74% compliance. Although compliance rates approaching 100% have been reported, in the Netherlands compliance is generally low, 6 making the ability to improve, rather than absolute compliance, acceptable and relevant as an outcome.
We performed a single-centre study; our findings may therefore not be completely generalizable. However, a multicentre study would present problems of comparability because we aimed to assess the influence of safety culture on the ability to improve when all prerequisites for optimal compliance have been met, and, most importantly, are the same for all units. In addition, we selected units to represent an average cross-section of a hospital, thus enhancing generalizability. Safety culture is a complex topic, and its role in the ability to improve has not been previously defined. Therefore, we gained in- 33 34 Chapter 2 of handhygiene compliancedata. Werff,P.W.Laar,der Dr van and S.D. Dr collectionde the to contributions their for Wijk, van van H. Kaiser, A.M. Drs Armstrong, L.A. thank to like would authors The ACKNOWLEDGEMENTS might culture safety prove pivotaltothesuccessofimprovement programs. unit of level high a hinder that Factors general. in strategies findings, therefore, do not apply to hand hygiene alone but possibly to improvement although hand hygiene is an essential aspect of safe care, it is only one of many. Our when they are applied in hospital units with a low level of safety culture. In addition, compliance affect not may interventions time-consuming and Costly interventions. Our findings may have important implications for the implementation of hand hygiene safety culture, couldinvestigatethismore explicitly. of levels low targeting trials interventional especially studies, Future improvement. (e.g., through team-building exercises) could provide the changes needed to achieve components of unit culture. Resolving these issues before implementing interventions this confirm relationship. In further our study, could teamwork and addressing interviews, noncompliance proved through important preferably interventions, after and safety culture and the ability to improve. Repeating safety-culture assessment before To our knowledge, our study is the first exploration of the relationship between level of in catheter-associated infections were not associated with changes in safety culture. interventions, although a recent study showed that successful improvement strategies can positively influence teamwork. In our study, safety culture may have improved with goalsame the toward together working well; as hypothesized been has relationship reverse a change, for prerequisite a be to appears culture safety strong a Although low- performing unitswere unmistakable,indicatingstrong associations. and high-performing the between differences small, was sample our Although saturation. data achieved we which with view, of points nursing and medical both as guide. depth knowledge by adapting the most commonly used questionnaire for our interview 36,37 Both management and non-management perspectives were obtained, as well 38
SUPPLEMENTARY MATERIAL
Category Intervention Target Description Preparation Determining goals Knowledge Consult with medical and nursing staff to determine Tools&skills specific and realistic goals in improving hand hygiene Attitude compliance 2 Strategic placement of Tools&skills Increase number of dispensers in hospital unit. Review dispensers dispenser location in consultation with staff Feedback & Reflection Team training ‘Feedback’ Knowledge Train healthcare workers to accept feedback on their Attitude actions and simultaneously learn to address a co-worker’s behaviour Buddy system Knowledge Pair two healthcare workers to provide each other with Attitude feedback on hand hygiene compliance Education & Awareness E-learning Knowledge WHO’s 5 Moments of hand hygiene, technique and its importance SureWash* Tools&skills Mobile training and audit device, using game technology to map and improve hand hygiene techniques Black Box Training Tools&skills Point out deficiencies in hand hygiene technique, with the use of a fluorescent alcohol based hand rub and a UV light to show which areas were overlooked. Pamphlets for patients and Knowledge Create awareness in visitors and patients on importance visitors of hand hygiene Face-to-face education Knowledge Provide staff education on hand hygiene technique, and Attitude the possible consequences of non-compliance for patients and staff Photo- and Video materials Knowledge Show good examples by only displaying images of health Attitude care workers that comply with hospital guidelines Social environment Champions Attitude Encourage hand hygiene behaviour by appointing well- performing health care worker as unit champion Reminders Knowledge Develop work place reminders for use throughout unit in consultation with staff
TABLE S1 Overview of interventions in the ‘Hand hygiene improvement Toolkit’ *SureWash (Glanta Ltd, Dublin, Ireland) is a device that uses video-measurement technology and immediate feedback to teach health care workers the WHO’s 5 moments of hand hygiene.
35 36 Chapter 2 improve compliance. to action of plan unit’s the general and error in to the response both as defined and improvements’, and ‘Feedback renamed was errors’ from learning and ‘Feedback error’ to response ‘Non-punitive error, an as registered not usually is hygiene hand with compliance specifically. Non- culture, hygiene hand and general in culture safety both measure to aimed We hierarchy’. and ‘Teamwork into unit’ hospital within ‘Teamwork and dimension, one in grouped usually is collaboration assessment, culture safety In made. were adaptations few a units. individual on thereforeassessment, the of validity compromise culturewould dimensions these excluding safety rendering of level, assessment hospital for the useful less at them clustered are dimensions COMPaZ the of Three Adaptations andadditionstotheinterviewguide TABLE S Feedback andimprovement Addressing non-compliance Adequate staffing Leadership Hospital managementsupport changes Shift Reporting Communication Overall perception ofsafety Teamwork and hierarchy Dimensions 2. Dimensionsoftheinterviewguide,adaptedfrom theCOMPaZ Questionnaire
was therefore renamed ‘Addressing non-compliance’. Likewise, non-compliance’. ‘Addressing renamed therefore was worker’s onthesemeasures. perspectives are taken withinthehospitalunitto increase handhygiene compliance andthehealthcare How to ahospitalunitreacts theirhandhygiene compliance scores. measures Assesses that compliance. Also assessesreasons for (not)addressing. The extent to whichhealthcare workers correct can colleagues ofhandhygiene incase non- and assessestherelationship withhandhygiene compliance. The amount andnursingstaff ofmedical available for theunit. Measures perceived workload personal involvement andmanagement style. Commitment towards handhygiene asexpressed by hospitalunitmanagement. This includes measures andhow theyinterpret them. measures at thehospitalunitlevel. whetherhealthcare Assesses workers are aware ofthese Measures ofhospitaladministration concerning handhygiene andinterpretation ofthese applied. Information transfer changes, duringshift includingstructure, procedures andactivities severity events. ofreported The withwhichadverse frequency events andincidents are reported. Also includesthe the hospitalunit. safety. This includestheway information iscommunicated amonghealthcare workers within The extent to freely whichindividualscan express ideasandopinionsconcerning patient onbutalsoincludeshandhygiene.focused Values andbeliefsofahealthcare worker towards patient ingeneral. safety Not specifically within thehospitalunit. maintains withcolleagues andtheway theycollaborate. Also includeshierarchical order Collaboration between healthcare workers. asthe Defined relationship anindividual Description 2 we therefore combined ‘Collaboration across hospital’ across ‘Collaboration combined therefore we 1 However, References 1 Smits M, Wagner C, Spreeuwenberg P, Van Der Wal G, Groenewegen PP. Measuring patient safety culture: an assessment of the clustering of responses at unit level and hospital level. Qual Saf Health Care 2009; 18: 292-6. 2 Halligan M, Zecevic A. Safety culture in healthcare: a review of concepts, dimensions, measures and progress. BMJ Qual Saf 2011; 20: 338-43. 2
Medical director Nurse manager Doctor Nurse Total
Unit 1 1 1 1 2 5
Unit 2 0 1 1 3 5
Unit 3 1 1 1 1 4
Unit 4 1 1 1 2 5
Unit 6 0 1 1 3 5
Total 3 5 5 11 24
TABLE S3. Distribution of interviewees among hospital units
Interview guide I. Introduction 1. Let’s start by having you briefly describe what you do here. 2. How long have you held this position? How long have you been working on this unit?
II. Hand hygiene 3. How would you describe your unit’s view on hand hygiene? 4. Have there been efforts to improve hand hygiene? a. Are you aware of the ‘Hand hygiene improvement Toolkit’? b. If so, has the Toolkit been used? And if so, which interventions have been implemented? c. Do you feel improvements have been made in compliance? 5. On your unit, what do you think contributes to (not) being able to improve? 6. Does your unit have a designated ‘Hand hygiene improvement team’? If so, does the team comprise both doctors and nurses? 7. Do you know who your designated infection control nurse(s) is/are?
37 38 Chapter 2 IV. General safetyculture III. Safetyculture andhandhygiene 17. 16. 15. 14. 13. 12. 11. 10. 9. 8. How are shiftchangesorganized onyourunit? unit? your on handled is issues safety patient of reporting how describe you Can How wouldyoudescribehierarchy onyourunit? How wouldyoudescribecollaboration andcommunicationonyourunit? How wouldyoudescribeyourunit’sgeneral viewonpatientsafety? How wouldyoudescribeyourunit’sworkload? staff? Ifso,how?Howisthisinformationhandled? withcommunicated measurements hygienecompliance hand of resultsAre compliance? Doyou,personally, address non-compliance?Why(not)? non- on co-workers address to unit your in customary it is extent Towhat improve handhygiene? to need the express management unit does way what in opinion, your In involvement inhandhygiene? their show administration hospital the does way what in opinion, your In b. a. b. a. c. b. a. a. r ‘ericdns rpre (ro i dsoee ad corrected without harmtothepatient)? and discovered is (error reported ‘near-incidents’ Are Is itcustomarytoreport incidents? Between nursesanddoctors? Among nurses/doctors? Do youconsiderhandhygiene partofpatientsafety? safety issues? patient on opinions or ideas expresses someone if happens What Are measures takentoimprove patientsafety? To what extent does workload influence hand hygiene compliance? Category Intervention Target Description Preparation Determining goals Knowledge Consult with medical and nursing staff to determine specific Tools&skills and realistic goals in improving hand hygiene compliance Attitude Strategic placement of Tools&skills Increase number of dispensers in hospital unit. Review dispensers dispenser location in consultation with staff Feedback & Reflection Team training ‘Feedback’ Knowledge Train healthcare workers to accept feedback on their actions 2 Attitude and simultaneously learn to address a co-worker’s behaviour
Buddy system Knowledge Pair two healthcare workers to provide each other with Attitude feedback on hand hygiene compliance Education & Awareness E-learning Knowledge WHO’s 5 Moments of hand hygiene, technique and its importance SureWash* Tools&skills Mobile training and audit device, using game technology to map and improve hand hygiene techniques Black Box Training Tools&skills Point out deficiencies in hand hygiene technique, with the use of a fluorescent alcohol based hand rub and a UV light to show which areas were overlooked. Pamphlets for patients Knowledge Create awareness in visitors and patients on importance of and visitors hand hygiene Face-to-face education Knowledge Provide staff education on hand hygiene technique, and the Attitude possible consequences of non-compliance for patients and staff Photo- and Video Knowledge Show good examples by only displaying images of health care materials Attitude workers that comply with hospital guidelines Social environment Champions Attitude Encourage hand hygiene behaviour by appointing well- performing health care worker as unit champion Reminders Knowledge Develop work place reminders for use throughout unit in consultation with staff
TABLE S4 Interview results per hospital unit, grouped according to the 10 dimensions
TABLE S5 Interview results per hospital unit, grouped on the 10 dimensions (next page)
39 40 Chapter 2
Dimensions Unit 1 Unit 2 Unit 3 Unit 4 Unit 6 Teamwork and Pillars rather than hierarchical layers. Pillars rather than hierarchical layers. Some hierarchy. Some hierarchy, Some hierarchy. hierarchy Close collaboration between doctors Close collaboration between doctors Close collaboration within each top-down management. Overall friendly collaboration, but and nurses and nurses hierarchical layer Acknowledge need for collaboration verbal aggression occurs among staff. and take actions to improve. Young and Focus on individual performances flexible team Overall perception Patient safety is priority number one. Patient safety is priority number one. Patient safety is very important. Hand Improvement in patient safety is Patient safety is an integral part of of safety Aware of consequences of hand hygiene Hand hygiene is part of patient safety hygiene is part of patient safety, but a important. Hand hygiene is an integral health care. Varying opinions on non-compliance. Medical staff can be subordinate part. Medical staff can be part of work, but a subordinate part of whether hand hygiene is part of patient sceptical of need for improvement sceptical of need for improvement patient safety safety Communication Formal communication. Formal communication. Formal communication. Formal and informal communication Formal communication. Bulletin board for important acute (i.e. during coffee breaks). topics. Combined ward; larger specialty All staff are allowed to express ideas All staff are allowed to express ideas or On paper, all staff are allowed to actively seeks ideas and opinions, Expression of ideas and opinions is and opinions options, as long as it has been thought express ideas and opinions. In practice, smaller specialty tends to ignore nurses’ limited to hierarchical layers out as a plan of action. This is actively expression is limited to hierarchical opinions stimulated layers Hand Results communicated with staff via Results communicated with staff via Results irregularly communicated with Results irregularly communicated Results irregularly communicated with hygiene email or during rounds email or unit log staff via e-mail and newsletters. Staff with staff via e-mail, notice of positive staff via email results Hand hygiene subject of work meetings Hand hygiene subject of work meetings try to disseminate results through results is lacking. Hand hygiene not a subject of work and newsletters and newsletters presentations. Hand hygiene subject of work meetings meetings Hand hygiene subject of work meetings Reporting Most reporting unit of the hospital. Everything out of the ordinary is being Incidents concerning patient safety are A lot is reported, but reporting is Reporting is good. Acknowledge Acknowledge that many (near) reported. Acknowledge that reporting always reported. Near-incidents are limited by increased workload. that many (near) incidents still go incidents still go unreported could be improved infrequently reported, depending on Reporting remains infrequent unreported the situation Shift changes Standardized shift changes, includes Standardized shift changes, includes Not completely standardized. Generally Standardized shift changes, includes Standardized shift changes, includes plenary information transfer, reading plenary information transfer, reading includes reading patient files and reading patient files and joint bedside plenary information transfer and patient files, and joint bedside safety patient files, and joint bedside safety questions for relieving colleague safety checks reading patient files. Recently added checks checks joint bedside safety checks Hospital management support Perceived investments Guidelines could be tightened. If Investments in department of infection Investments in poster campaigns and Investments in poster campaigns, Investments in posters campaigns management sets demands, they control and purchase of better alcohol hand hygiene research tightening guidelines should facilitate based hand rub Perceived Hospital management is not Staff are divided on perceived hospital Hospital management sets demands, Hospital management sets demands, Staff does not perceive hospital support responsible, leadership in hospital unit management support of hand hygiene staff should meet these, hospital unit staff should meet these, hospital unit management support of hand hygiene is more important is responsible is responsible Hand hygiene element of strategic of strategic element Hand hygiene pass governmental plan, but only to and gain accreditation requirements perceived or follow-up feedback No bed side initiated Medical director based hand rub. of alcohol availability but relocated Nurse manager was Decision- delayed. was replacement among nursing staff. making no clear leadership Currently not workload Increased High workload. non- for excuse legitimate considered a negative but can have compliance, influence each other on non- do not address Staff performance focus on own compliance, Sceptical of opportunities for possible Acknowledges improvement. little to Performs use of interventions. compliance improve to no interventions 4 Interventions: Pathological 2 Hospital management have made made have management Hospital but staff find a priority, hand hygiene lowered. is now attention it frustrating important of element Hand hygiene plan, it is made clear that strategic things should change explain to required units are Hospital in stand-up results compliance meetings with hospital management present unit management Hospital non- models and address as role enhancing aim at Generally compliance. spirit but demand hand hygiene team compliance. zero-tolerance approach, Top-down policy of highest workload Self-proclaimed is part Hand hygiene of the hospital. workload on of influence slight routine, compliance each other on non- address Staff layers hierarchical across compliance, opportunities of own for Aware interventions Performs improvement. compliance improve to 9 Interventions: Proactive Hospital management have made hand made hand have management Hospital a priority hygiene explain to required units are Hospital in stand-up results compliance meetings with hospital management non- addresses Medical director but nurse manager is compliance, interventions. of hand hygiene unaware for responsible Nursing staff strategy. improvement no in addressing, approach Top-down improvement to clear approach workload Increased High absenteeism. hygiene hand influences negatively compliance Medical improvement. Room for compliance, in inconsistent staff are nursing staff by hindering addressing of opportunities for Little awareness improvement. to no interventions little to Performs compliance improve of hand Nurse manager not aware on unit interventions hygiene 4 Interventions: Calculative Hospital management have made hand made hand have management Hospital a priority hygiene in mentioned regularly Hand hygiene plenary meetings, thinks hand management Indicating is important hygiene hospital unit involved Closely Nurse manager actively management. guideline adherence, promotes staff in Involves model. as role presents decision making. top-down and bottom-up Combined approach priority is Hand hygiene High workload. (e.g. in emergency situations lowered resuscitation) according improvement Room for Non-compliance management. to according appropriately addressed staff to Sees little opportunities for consistently considering improvement performs Still high compliance. compliance improve to interventions 6 Interventions: / Generative Proactive Hospital management have made made have management Hospital Hand hygiene a priority. hand hygiene plan, but targets of strategic element feasible not always e-mails hospital many from Too comply to reminding management hospital unit involved Closely clinical with regular management in decision- involved are Staff duties. staff are experienced making, models. as role addressed top-down and bottom-up Combined approach priority is Hand hygiene High workload. (e.g. in emergency situations lowered resuscitation) each other on non- address Staff for is room but there compliance, improvement opportunities of own for Aware interventions Performs improvement. compliance improve to 8 Interventions: / Generative Proactive
41 Perceived Perceived prioritization & Feedback follow-up Leadership Adequate staffing Addressing non- compliance and Feedback improvement Safety culture 42 Chapter 2 4 3 2 1 REFERENCES 8 7 6 5 15 14 13 12 11 10 9 23 22 21 20 19 18 17 16 compliance withhandhygiene. Control Infection Programme. the role ofimproved practices. control inhealthcare institutions. guidelines:anarrativeclinical practice review. guidelines inhospitalcare. hygiene improvement strategies: abehavioural approach. cluster randomised controlled trial. different strategies for promoting hand hygiene inhospitalnurses:aprocess evaluation alongside a 21 initiative infections:results onhealthcare-associated ofaninterrupted timeseries. with increased handwashing anddecreased nosocomial infections. Patient Saf Care in multimodalintervention five-unit abefore-and-after contact: Tuscany. variation inhandhygiene compliance rates. heterogeneitymarked dueto localculture? 2008; andevidence base. policy critiquing hand hygiene improvement program. culture. Healthc Q onPatient‘Hospital Survey Safety Culture’ inDutch hospitals. rates? Aqualitative study. mortality infarction Hand Hygiene Technical Reference Manual hand hygiene observations. Pittet D, S HugonnetS,Harbarth Pittet D, Allegranzi B, H Sax S,HelingG,Borg Bono MA.De Organizational culture anditsimplications for infectionprevention and P,Dodek Cahill NE, HeylandDK. The relationship between organizational culture andimplementation of Erasmus V, Daha TJ, BrugH Huis A, Van Achterberg T, BruinM,Grol De R,Schoonhoven L,HulscherM.Asystematic review ofhand Huis A,HollemanG, Van Achterberg T, Grol R,Schoonhoventwo L,HulscherM.Explainingtheeffectsof JA, Ptak RA, KB, Lasky HomaKA, TaylorKirkland ofahospital-wide handhygiene EA,SplaineME. Impact Peterson TH, Teman SF, Connors RH. A safety culture transformation: its effects at a children’s hospital. A Saint S,Conti A,Bartoloni KB. steps inahandhygiene next Determining Kirkland improvementHoma K, initiative by examining Cantrell D, O, Shamriz Cohen MJ, Stern Z,BlockC,Brezis M.Handhygiene compliance by physicians: Creedon SA.Handhygiene compliance: variations exploring between hospitals. inpractice DJ,Gould Hewitt-Taylor J, Drey J, NS,Gammon ChudleighJ, Weinberg JR. The CleanYourHandsCampaign: Tromp Guchteneire M,HuisA,De I Parker D, Lawrie M,HudsonP. Aframework for understandingthedevelopment oforganisational safety Westrum oforganisational R.Atypology cultures. Law MP, R,BakerGR,Smith Zimmerman T. Assessment ofsafety culture inahospitalsetting. maturity I,Smits M,Christiaans-Dingelhoff Wagner C, Wal G,Groenewegen PP. ofthe The psychometric properties LA,Spatz E,E Cherlin Curry CS,Severson MA,Hlady Segre AM, Polgreen PM. Amobilehandheldcomputing application for recording E,Larson EL,Early CloonanP, Sugrue S,Parides M.An organizational climate associated intervention : 1019-26. 2009; 104 Safety Science Safety 2010; : 32-5. 2012; 18 : 429-33. 13 Spec No13 Spec 8 : 125-30. 2006; etal Infect ControlInfect HospEpidemiol etal : 110-5. 44 Infect ControlInfect HospEpidemiol et al etal : 551-62. The Lancet Diseases Infectious . Evidence-based model for . hand Evidence-based transmission patient during care and . Improving healthcare worker handhygiene adherence before patient etal J HospInfect . hospitalsinacute myocardialWhat distinguishestop-performing . Systematic review ofstudiesoncompliance withhandhygiene Implement Sci etal J HospInfect . andlong-term effectivenessThe ofamultidisciplinary short-term Am J Infect Control JInfect Am . Geneva: . Geneva: World HealthOrganization; 2009. . Effectiveness ofahospital-wide programme to improve Am J Infect Control JInfect Am Qual ManagHealthCareQual 2014; Ann Intern Med Ann JPEN JParenter Enteral Nutr 2007; 2013; Quality and Safety inHealthCare andSafety Quality 86 : 1-6. 65 8 2010; 2012; 2010; : 41. : 95-101. Implement Sci 2006; 2011; BMC Health Serv Res BMC HealthServ 2009; 31 Lancet 40 31 : 283-94. : 732-6. : 975-7. 6 154 Behav Med Behav : 641-52. 2011; 37 2000; : 301-5. : 384-90. 2012; 2010; 20 Quality and Safety inHealth andSafety Quality 356 : 116-21. 2000; 7 : 1307-12. 34 : 92. 2008; 2004; : 669-74. BMJ Qual Saf BMJ Qual 26 : 14-22. 8 13 : 230. : ii22-ii7. Nurs Times 2012; J
24 Organizational tools. World Health Organisation website. http://www.who.int/patientsafety/research/ methods_measures/human_factors/organizational_tools/en/. Published 2017. Accessed May 10, 2017. 25 Young-Xu Y, Neily J, Mills PD et al. Association between implementation of a medical team training program and surgical morbidity. Arch Surg 2011; 146: 1368-73. 26 Neily J, Mills PD, Young-Xu Y et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010; 304: 1693-700. 27 Epps HR, Levin PE. The TeamSTEPPS Approach to Safety and Quality. J Pediatr Orthop 2015; 35: S30-3. 2 28 Kilbride HW, Powers R, Wirtschafter DD et al. Evaluation and development of potentially better practices to prevent neonatal nosocomial bacteremia. Pediatrics 2003; 111: e504-18. 29 Cumbler E, Castillo L, Satorie L et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual 2013; 28: 304-11. 30 Kilbride HW, Wirtschafter DD, Powers RJ, Sheehan MB. Implementation of evidence-based potentially better practices to decrease nosocomial infections. Pediatrics 2003; 111: e519-33. 31 Hoyt DB. Looking forward. How Memorial Hermann Health System innovative approach to improved surgical quality and patient safety. Bull Am Coll Surg 2013; 98: 7-8. 32 Pronovost P. Interventions to decrease catheter-related bloodstream infections in the ICU: the Keystone Intensive Care Unit Project. Am J Infect Control 2008; 36: S171 e1-5. 33 Jain R, Kralovic SM, Evans ME et al. Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. N Engl J Med 2011; 364: 1419-30. 34 Hessels AJ, Genovese-Schek V, Agarwal M, Wurmser T, Larson EL. Relationship between patient safety climate and adherence to standard precautions. Am J Infect Control 2016; 44: 1128-32. 35 Hagel S, Reischke J, Kesselmeier M et al. Quantifying the Hawthorne Effect in Hand Hygiene Compliance Through Comparing Direct Observation With Automated Hand Hygiene Monitoring. Infect Control Hosp Epidemiol 2015; 36: 957-62. 36 Fleming M. Patient safety culture measurement and improvement: a “how to” guide. Healthc Q 2005; 8 Spec No: 14-9. 37 Nieva VF, Sorra J. Safety culture assessment: a tool for improving patient safety in healthcare organizations. Qual Saf Health Care 2003; 12 Suppl 2: ii17-23. 38 Meddings J, Reichert H, Greene MT et al. Evaluation of the association between Hospital Survey on Patient Safety Culture (HSOPS) measures and catheter-associated infections: results of two national collaboratives. BMJ Quality & Safety 2017; 26: 226-35.
43 Human behaviour flows from three main sources: desire, emotion, and knowledge - Plato CHAPTER 3 3
Effectiveness of a behavioural approach to improve healthcare worker compliance with hospital dress code
Mireille Dekker Martine G. Caris Anne M. van Gunsteren Rosa van Mansfeld Cees Lucas Christina M.J.E. Vandenbroucke-Grauls
Infection Control and Hospital Epidemiology, December 2017 46 Chapter 3 to otherguidelines. with compliance sustain hospital and dress code. increase This combined to approach may method also be useful effective to improve an adherence is approach action CONCLUSION compliance by39.6%(95%CI31.7–47.5). overall increased causes these at targeted interventions Tailored HCWs. of groups the main causes of noncompliance. The importance of each cause varied for different RESULTS specific groups ofHCWsandspecificdepartmentsthrough to participatoryaction. tailored and prioritized, developed, were that interventions for input as served group technique was applied to assess causes of noncompliance. The causes revealed nominal a measurement, baseline the of outcome the on Based measurements. up adherencepolicy,for the hallways to hospital in observed follow- at and baseline, at METHODS group techniquewithparticipatoryaction)iseffectiveinimproving compliance nominal a (combing approach behavioural a whether assess to and noncompliance OBJECTIVE noncompliance. of causes main the at targeted interventions by adherence improve to poor,sought all was we compliance for Because care. policy patient direct ‘bare-below-the-elbow’ in a (HCWs) workers and healthcare hospital the by includes It provided guidelines. uniforms national on based code dress a adopted has Netherlands, BACKGROUND ABSTRACT We identified lack of knowledge, lack of facilities, and negative attitudes as ewe Mrh 04 n Jn 21, ttl f ,2 HW were HCWs 1,920 of total a 2016, June and 2014 March Between o esr cmlac wt te rs cd, o ses ass of causes assess to code, dress the with compliance measure To h cmiain f nmnl ru tcnqe n participatory and technique group nominal a of combination The h V Uiest Mdcl etr a etaycr hsia i the in hospital tertiary-care a Center, Medical University VU The INTRODUCTION
To prevent transmission of pathogens and healthcare-associated infections, proper infection control is paramount. Hand hygiene has proven very important in the prevention of healthcare-associated infections,1 but adherence is low. 2,3 In addition, proper hand hygiene is hindered by rings, wristwatches, and long sleeves. 4,5 Through jewelry,6,7 artificial nails,8 and clothing9-11 healthcare workers (HCWs) can transfer microorganisms to patients, colleagues or themselves. Therefore, a hospital dress 3 code has been defined for HCWs in direct patient care at the VU University Medical Center, a 713-bed tertiary-care hospital in the Netherlands. The dress code entails proper wearing of hospital uniforms and a ‘bare-below-the-elbow’ policy. Although the hospital has set these standards and provides clean uniforms and scrubs every day, compliance with the dress code was poor.
To structurally improve guideline adherence, behavioural change is required. Group norms tend to guide behaviour of group members and, therefore, may play an important role in the individual willingness to comply with infection prevention policies.12,13 To achieve behavioural change, insight is needed into the interaction between individuals, groups, and the working environment and its effect on compliance. The nominal group technique (NGT) is a decision-making method that involves various panel rounds and combines elements from focus groups and the Delphi method. This structured group process can be used to generate ideas, to reach consensus, and to engage group members in possible ways to solve a problem. 14,15 The NGT has proven useful in a range of healthcare settings. 16 Its democratic style, the iterative character, and the avoidance of bias caused by interpretation of the researcher has been shown to promote a high-volume of high quality responses. 17 Therefore, NGT can help to gain insight in behavioural components and other aspects of noncompliance.
Participatory action research (PAR) is a collective inquiry of researchers and participants aimed at understanding and improving a process. 18 It is an empowering approach to guideline implementation in healthcare settings. 19 Because a PAR approach focuses on adapting interventions to the existing needs of an implementation situation, it might be a suitable approach to enhance compliance. 20 We hypothesized that combining PAR with NGT could create behavioural change and improve compliance with our hospital’s dress code. Therefore, we aimed to measure compliance with the dress code, to assess causes of noncompliance, to devise an approach to improve compliance by PAR, and finally, to assess whether this approach was effective in improving compliance. 47 48 Chapter 3 irregular intervals(T2–T8)thereafter, from March 2014toJune2016. observations over all 8 time points. Compliance was measured at baseline (T1) and at (80 physicians, 80 nurses, and 80 other HCWs) were scored, for a total of 1,920 HCWsHCW 240 measurement, each At items. all to adherence as defined was protocol’ thewith ‘Compliant dresscode. the of item every with scoredcompliance and HCW card and therefore are a reliable means of identification. Observers noted the type of theirjob-specific by HCWs other or uniforms. Job-specific uniforms are provided nurses in accordance with physicians, hospital identification as identified were HCWs infection observations. these an for specifically trained both researchnurse, a and expert control by hallways hospital in observed covertly where workers Healthcare Measurement ofCompliancewiththeDress Code TABLE 1 (full descriptioninTable 1). nails and hair,beards, of keeping for guidelines the to adhere to (3) and watches); no jewellery,and the wrist or to hand no adhere sleeves, long to (no policy (2) ‘bare-below-the-elbow’ contaminated; visibly become they if sooner or day, a once least at these change to and care patient direct in when scrubs or uniforms hospital Netherlands. the in guideline development prevention infection for organization independent an (WIP), Prevention Infection on Group Working the by guidelines on based is code dress hospital The Hospital Dress Code METHODS Nails Beards/moustaches Rings Watch or wristjewellery Length ofsleeves Hair Uniform Item Hospitaldress codebasedonDutchnationalguidelines Nails are short and clean, no artificial nailsornailpolish andclean,noartificial Nails are short Worn andgroomed short No rings No watches, wristjewellery, piercings inhandorlower arm Uniform sleeves are worn above theelbow, sleeves ofpersonalclothing notvisible the shoulder Long hairisworn up, are nottouching visiblycleanandnotworn theshoulder;headscarves over Uniform iscomplete, visiblycleanandworn closedandexchanged for acleancopyday every Criteria 21 h des oe eurs l HW () o wear to (1) HCWs all requires code dress The Nominal Group Technique In our hospital, a network of link nurses is operational for improvement of infection control practices. These nurses work on clinical wards or outpatient clinics and act as a link between their own unit and the infection control team. After regular training sessions, link nurses are asked to raise awareness on the discussed topic and to implement accompanying policies by motivating their colleagues to improve clinical practice. 3 In one of the training sessions, the link nurses were educated in the utility and necessity of the hospital dress code, were trained to observe compliance in their own ward, and were asked to assess causes for noncompliance. To allow the link nurses to fulfil their role, we modified the technique and used 2 consecutive digital sessions to generate an overview of the main causes of noncompliance. In the first session, the link nurses were invited (by e-mail) to discuss the causes of compliance and noncompliance with colleagues on their own ward and to report their findings.
In a second session, the answers were verified; we checked whether all main causes had been identified by presenting the link nurses with an overview of all input. In this session, link nurses were also asked to discuss and prioritize possible solutions with their colleagues. These findings were presented for discussion at meetings of the Nursing Advisory Council and the Medical Staff Advisory Board. With the input of these forms, the overview was finalized, and a consensus was reached regarding the 3 main causes and the priority of interventions.
We combined these outcomes to develop a set of interventions tailored to each group of HCWs or department. Interventions were implemented in collaboration with the link nurses, hospital management, and other relevant stakeholders (PAR). Details of the timeline of the project, and of the final, refined strategy are outlined in Table 2.
The Medical Ethics Committee of VUmc assessed the study and concluded that our study deemed exempt from their approval, as it did not include collection of data at the level of patients.
Statistical Analysis Analyses were performed per type of HCW, per item, and overall for compliance. Results were expressed as proportion of HCWs compliant with hospital dress code. Confidence intervals (CIs) were calculated using Wilson’s score. The Taylor series were used to calculate CIs for difference scores. An ordinary least squares regression model was fitted to identify the change in compliance over time using a linear spline with a 49 50 Chapter 3 compliance. improving for facilitators possible as identified were protocol clear a providing and measure prevention infection an as policy the of purpose the Clarifying discussion. and confusion to led which interpretation, to open were items unclear.Some items employee. Furthermore, nurses and physicians found the description of some protocol hospital a as recognizable be to jacket a wore they that mentioned clinic outpatient the in positions administrative with Colleagues policy. hospital the from deviation detailed had their own wards policies and created Several their behaviour.own routines habitual without knowledge of as their routines uniform their described Nurses Lack ofknowledge of facilities,andnegativeattitudes. The causes of noncompliance were divided into 3 main areas: lack of knowledge, lack Main Causes ofNoncompliance uniform). of this group wore incomplete uniforms (e.g., only the jacket instead of the complete members many Also, wristwatches. and rings, sleeves, long wore group this HCWs; with the ‘bare-below-the-elbow’ policy. Most deviations were observed for the other compliant less were they therefore, sleeves; long and wristwatches wear to tended likely to comply with the uniform item than physicians or other HCWs. Physicians also morewere Nurses uniforms. their of wearing appropriate with compliant least were HCWs items, other to Relative protocol. the of items all with compliant were HCWs overall otherof quarter a than more just and physicians, the of half than less nurses, the of higher showed two-thirds measurement, first Nurses this In HCWs. other material). and physicians than compliance supplementary in 3 (Table HCWs separately of group each for and overall, item, per analysed were results Compliance Baseline Compliance(T1) RESULTS Statistical Computing,Vienna,Austria). for Foundation (R strategies modelling regression for 5.0-0 version package R with performed were analyses All HCWs. of groups the between effects interaction and knot at T2 and an interaction term to assess the effects of the implementation strategy 22,23 Lack of facilities Healthcare workers reported the limited range of uniforms and poor fit as reasons for not wearing the uniform. In particular, nurses described the need for a jacket for warmth during nightshifts. Physicians reported the queue at the distribution point and its location as causing too much delay in obtaining a clean coat and therefore a ‘loss of time.’ The lack of availability of distribution points, uniforms, lockers, and dressing rooms appeared to be the key barrier to compliance; providing extra facilities was identified as a necessity for improving compliance. 3
Time, months Intervention Measurement 1 Pilot 2 3 T1 3.5 Stakeholders informed on results of baseline measurement 4.5 Link nurses educated on hospital dress code, trained to monitor compliance in their own ward. Start of the nominal group technique. Hospital management re-informed employees on the dress code and communicated this extensively 5.5 Completion of the nominal group technique 6 Extra means allocated, (expansion of range and number of uniforms, increase of number of wardrobes and lockers) 8 T2 9 Introduction of role models; evaluation of all hospital-related stock photos for correct display according to dress code; poster campaign addressing the responsibility of each healthcare worker to comply with the policy and give positive feedback to compliant colleagues 10 The hospital management initiated a feedback culture and started addressing healthcare workers who did not comply with the protocol 11 T3 13 T4 15 Second poster campaign 16 T5 20 T6 22 A brochure was released with the dress code and presented in person to the head of each department or ward. Causes of non-compliance again were discussed per ward. Strategies to achieve compliance were tailored by department 23 All healthcare workers with consent of the company for the home laundering of the uniform were personally contacted and instructed with regard to this home laundering 26 In a concluding report to hospital management the advice was given to secure obtained results by using periodic measurements as steering information in guidance within the various divisions of the hospital 26.5 T7 30 T8
TABLE 2 Project Timeline 51 52 Chapter 3 wristwatches, andincompleteuniformstoimprove compliance. wore also wristwatches Physicians and long sleeves uniform. less often. Other their HCWs wore fewer long of sleeves, rings, wearing appropriate with compliant more of the all for significantly improved weregroups All material). (Tableprotocol had supplementary the in of 3 items particular compliance project, the of end the At = .06),whichindicatestheinterventionstrategy hadsimilarefficacyonallgroups. strategyintervention the of differentthe in groups (P effect non-significant a yielded effect the for term interaction an Introducing nurses. and physicians of level the to complianceincreased eventually which group, this within compliance full achieve to strategies on focused we T7, and T3 Between HCWs. other for not but nurses and The increase in compliance was sustained throughout the study period for physicians 39.4–65.6), respectively. CI, (95% 52.5% and 14.6–40.5) CI, (95% 27.5% were increases these HCWs, other and nurses For period. study whole the over 24.7–52.8) CI, (95% 38.7% increased physicians of compliance The achieved. was =.01) P 0.0008; (β= 82.1% to 65.4% from compliance overall in increase significant additional an T7), to (T3 Thereafter focus on the dress code and addressing noncompliant employees were implemented. maintaining at aimed interventions improvement, this Tosustain period. 5-month a over .001) = P 0.04; = (β 65.4% 42.5%to from significantly, improved code dress the with compliance overall the employees, facilitating and knowledge improving at aimed interventions of set first the After (T1–T8). observations of period full the over group per compliance and compliance overall for results the displays 1 Figure Follow-Up Measurements (T2–T8) by otherHCWswere recommended toimprove compliance. confrontation. awareness among these role and models regarding their conflict negative improving influenceand on compliance management, avoid hospital by to supported culture, feedback models a Promoting role these address not did Nurses models. role these of status and seniority the of because difficult was nurses) and negative role models (i.e., heads of medical departments and experienced physicians the these Addressing models. from role negative of influence the mentioned Nurses protocol. deviate to the motivation to as contributes infections code healthcare-associated dress of prevention a that evidence of lack the mentioned Physicians Negative attitudes 3
FIGURE 1 Proportion of healthcare workers compliant with dress code
DISCUSSION
In this study, hospital-wide compliance with a hospital dress code improved significantly following a tailored intervention strategy. Interventions were based on the main causes for noncompliance, assessed using a nominal group technique (NGT) with stakeholders and a participatory action approach. The results showed an almost 40% absolute increase in compliance. Regular compliance measurements with feedback helped maintain improvement and focus on this hospital standard.
These results strengthen previous findings that, to improve compliance, exploration of barriers and facilitation measures is essential. 15 Compliance with guideline implementation is considered complex; therefore, assessing the main causes for noncompliance through NGT was the first step in our project, instead of the final product. Guideline implementation requires interventions that specifically target identified barriers and take into consideration the department, profession, and setting.19 PAR has been shown to be effective in different groups of HCWs in various fields of health care.24-26 Experiences in infection control show that a PAR approach is a potentially useful method to improve hospital-wide guideline adherence. 27 In this collaborative process, working with people in an educative and empowering manner 53 54 Chapter 3 hrfr, G ad h rslig alrd nevnin wr a rdc o our of product a were interventions tailored resulting the practices. and control NGT infection Therefore, hospital-wide improve to way viable a be to appears approach behavioural This apply. to easy is that method empowering an PAR with combined NGT makes flexibility its and approachpragmatic democratic, the Overall, for launderingbecausedataonthispartoftheprotocol were unavailable. uniformsthe of changing daily the with comply HCWs whether measure not did we likely.interventions Furthermore,the of result a as compliance in increase an makes whichmeasuredbaseline, those ratesat to compliance previoussimilar showed year the in audits However, interventions. baseline of set first standardizedthe of implementation the 1 before only performed We limitations. measurement. The initial steep increase in compliance could have been incorporated some has study Our noncompliance. Further studycouldspecificallyaddress thisaspect. in of Nurses cause important an as compliance. models role negative of presence encourages the described study our and norm the of perception the strengthens which effect, inhibition cross-norm so-called the evokes appropriately uniform the a with others behavior. HCW influence can norm specific of noncompliance based the Observing is models. role behaviour of collective behaviour the this on of Much improved. had itself compliance remained,but differences these project, the of end the At HCWs. of groups different the between differed highest was noncompliance which for items highlighted, As lead toasustainablebehavioural change groups. specific to interventions tailoring of and process the in HCWs involving actively of importance the emphasize findings These physicians. and nurses of those to comparable rates to increased compliance their which after interventions, the in HCWs these including started we project, the first interventions were not specifically tailored to their departments. Halfway through first set of interventions was applied in our hospital. In the group of other HCWs, the and nurses immediately showed a sustained increase in compliance over time after the project and to take the results from follow-up measurements into account. Physicians offered method this the of during flexibility the interventions adjust to possibility the process. research the during intervened deliberately we research, conventional to contrast reflection; and action, research, of process cyclical a is PAR stakeholders. all of possible exploring by solutions, noncompliance, and by solving the problem underlying through management support and involvement causes regarding discussion a essential. is 29 A i a ogig rcs rte ta a hr-em intervention, short-term a than rather process ongoing an is PAR 20 h ifcin rvnin em mrvd opine y initiating by compliance improved team prevention infection The 31 19 andwastherefore avoided. 32-34 A punitive approach generally does not does generally approach punitive A To wearand rolecomply a model see 30 and 28 in in particular process, and they were specifically applicable in our setting. Therefore, we recommend that this method be applied in other healthcare settings to develop interventions enhancing compliance with protocols and guidelines tailored to the local situation.
ACKNOWLEDGEMENTS 3 We would like to express our gratitude to our infection control link nurses network for their contribution to the nominal group technique and to all our role models for fulfilling this role. We acknowledge Liz Armstrong for contributing to the collection of the data and Martijn Stuiver for assistance with the statistical analyses. We also thank Paul van Wijk for contributing to the abstract that preceded this article.
55 56 Chapter 3 SUPPLEMENTARY MATERIAL nolongbeard longhairup nolongnails nolongsleeves nowristwatches norings compliant withprotocol Nurses nolongbeard longhairup nolongnails uniform nolongsleeves nowristwatches norings compliant withprotocol Physicians nolongbeard longhairup nolongnails uniform nolongsleeves nowristwatches norings compliant withprotocol Overall uniform 80/80 (100)[95.4–100] 72/80 (90)[81.5–94.8] 78/80 (97.5) 66/80 (82.5) 78/80 (97.5) 71/80 (88.8)[80.0–94.0] 71/80 (88.8)[80.0–94.0] 48/80 (60.00)[49.0–70.0] 80/80 (100)[95.4–100] 73/80 (91.3)[83.0–95.7] 80/80 (100)[95.4–100] 62/80 (77.5)[67.2–85.3] 49/80 (61.3)[50.3–71.2] 66/ 80(82.5) 74/80 (92.5)[84.6–96.5] 31/80 (38.8)[28.8–49.7] 240/240 (100)[98.4–100] 217/240 (90.4)[86.0–93.5] 234/240 (97.5)[94.7–98.8] 167/240 (69.6)[63.5–75.1] 191/240 (79.6)[74.0–84.2] 200/240 (83.3)[78.1–87.5] 211/240 (87.9)[83.2–91.5] 102/240 (42.5)[36.4–48.8] (% compliance)[95%CI] compliant proportion Baseline compliance(T1) [72.7–89.3] [91.3–99.3] [72.7–89.3] [91.3 –99.3] * (% compliance)[95%CI] compliant proportion Final compliance(T8) 226 /240(94.2)[90.4–96.5] 227/240 (94.6)[91.0–96.8] 233/240 (97.1)[94.1–98.5] 237/240 (98.8)[96.4–99.6] 197/240 (82.1)[76.7–86.4] 80/80 (100)[95.4–100] 76/80 (95)[87.8–98.0] 80/80 (100)[95.4–100] 75/80 (93.8) 80/80 (100)[95.4–100] 79/80 (98.8)[93.3–99.8] 80/80 (100)[95.4–100] 70/80 (87.5)[78.5–93.1] 80/80 (100)[95.4–100] 76/80 (95)[87.8–98.0] 80/80 (100)[95.4–100] 74/80 (92.5)[84.6–95.5] 72/80 (90)[81.5–94.8] 78/80 (97.5) 79/80 (98.8)[93.3–99.8] 62/80 (77.5)[67.2–85.3] 240/240 (100)[98.4–100] 231/240 (96.3)[93.0–98.0] 240/240 (100)[98.4–100] [86.2–97.3] [91.3 –99.3] * 24.6 [18.1–31.1] 15.0 [9.2–20.9] 13.8 [8.6–18.9] 10.8 [6.5–15.2] 39.6 [31.7–47.5] % [95%CI] difference score in ∆ T1-T8 - 5.0 [-3.1–13.1] 2.5 [-0.9–5.9] 11.3 [1.4–21.1] 2.5 [-0.9–5.9] 10.0 [2.7–17.3] 11.3 [4.3–18.2] 27.5 [14.6–40.5] - 3.8 [-4.1–11.6] - 15.0 [4.2–25.8] 28.8 [16.2–41.3] 15.0 [6.0–24.0] 6.3 [-0.01–12.5] 38.8 [24.7–52.8] - 5.8 [1.4–10.3] 2.5 [0.5–4.5] ** Other HCW compliant with protocol 23/80 (28.8) [20.0 – 39.5] 65/80 (81.3) [71.3 – 88.3] 52.5 [39.4 – 65.6] no rings 66/80 (82.5) [72.7 – 89.3] 78/80 (97.5) [91.3 – 99.3] 15 [6.0 – 24.0] no wristwatches 63/80 (78.8) [68.6 – 86.3] 76/80 (95) [87.8 – 98.0] 16.3 [6.1 – 26.4] no long sleeves 64/80 (80) [70.0 – 87.3] 75/80 (93.8) [86.2 – 97.3] 13.8 [3.5 – 24.0] 3 uniform 39/80(48.8) [38.1 – 59.5] 77/80 (96.3) [89.5 – 98.7] 47.5 [35.8 – 59.2] no long nails 76/80 (95) [87.8 – 98.0] 80/80 (100) [95.4 – 100] 5.0 [0.2 – 9.8] long hair up 72/80 (90) [81.5 – 94.8] 79/80 (98.8) [93.3 – 99.8] 8.8 [1.7 – 15.8] no long beard 80/80 (100) [95.4 – 100] 80/80 (100) [95.4 – 100] -
Table S1 Baseline and final compliance overall, per item and per group of healthcare workers * 95% confidence intervals were calculated using Wilsons’ score ** 95% confidence intervals were calculated using Taylor series HCW healthcare workers
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Pittet D, Allegranzi B, Boyce J, World HealthOrganization World Alliance for Patient Safety First Global Erasmus V, Daha TJ, BrugH Tromp Guchteneire M,HuisA,De I Pittet D, S HugonnetS,Harbarth Van BuulLW, JJ, Sikkens Van Agtmael MA, MH, Kramer Van Steen Der JT, CM.Participatory Hertogh Breimaier HE, Halfens RJ, Lohrmann C.Effectiveness ofmultifaceted andtailored strategies to implement Baum F, MacdougallC,SmithD. research. action Participatory Nominal Group Asmus CL, JamesK. Technique, Loafing, Social andGroup Creative Quality. Project Parker AW. NGT in Health Care Administration. Group Techniques for Program Planning: a guide to Carney O, Mcintosh J, Worth A. The useoftheNominal Group Technique inresearch withcommunity Delbecq AL, Vandeven, A.H., Gustafson, D.H., . Group Techniques for Program Planning: a guide to Erasmus VE. Compliance to HandHygiene GuidelinesinHospitalCare -Astepwise behavioural approach. Cialdini RB, Goldstein NJ. influence: Social compliance and conformity. Team R:Alanguageandenvironment RC. for statistical computing. Vienna, Austria: RFoundation for Taskforce Prevention. Infection Ziekenhuizen: Persoonlijke hygiëne medewerkers 2012. Harrell JrFE.Regression rms: Strategies. Modeling .5.0 ed2016.p. Rpackage. 2010; 2006; J Adv Nurs 74 60 : 16-21. : 854-7. 1996; 2014:CD003325. 2009; 23 2005; : 1024-9. Infect ControlInfect HospEpidemiol etal 30 : 427-32. The Lancet 17 etal . Systematic review ofstudiesoncompliance withhandhygiene : 349-54. etal etal . andlong-term effectivenessThe ofamultidisciplinary short-term Am J Infect Control JInfect Am . Associations contamination between bacterial ofhealthcare J Antimicrob Chemother J Antimicrob . Effectiveness ofahospital-wide programme to improve 2000; BMC Nursing 356 : 1307-12. J HospInfect Infect ControlInfect HospEpidemiol 2010; 2012; J HospInfect 2015; Am J Infect Control JInfect Am 31 40 Journal of Epidemiology andCommunity ofEpidemiology Journal 2014; : 283-94. 2015; : 732-6. 14 Annu RevPsycholAnnu : 18. 2007; 69 90 : 1734-41. : 285-92. 66 : 301-7. 2012; 2009; 2004; 40 : e245-8. 30 55 : 611-22. : 591-621. Cochrane J Hosp Infect Infect 24 Friesen-Storms JH, Moser A, Van Der Loo S, Beurskens AJ, Bours GJ. Systematic implementation of evidence-based practice in a clinical nursing setting: a participatory action research project. J Clin Nurs 2015; 24: 57-68. 25 Ramli AS, Lakshmanan S, Haniff J et al. Study protocol of EMPOWER participatory action research (EMPOWER-PAR): a pragmatic cluster randomised controlled trial of multifaceted chronic disease management strategies to improve diabetes and hypertension outcomes in primary care. BMC Fam Pract 2014; 15: 151. 26 Collet JP, Skippen PW, Mosavianpour MK et al. Engaging pediatric intensive care unit (PICU) clinical staff to lead practice improvement: the PICU participatory action research project (PICU-PAR). Implement Sci 2014; 9: 6. 3 27 Battistella G, Berto G, Bazzo S. Developing professional habits of hand hygiene in intensive care settings: An action-research intervention. Intensive Crit Care Nurs 2017; 38: 53-9. 28 Kindon S.L. PR, Kesby M. . Participatory action research approaches and methods: connecting people, participation and place. Routledge studies in human geography. London Routledge; 2007. 29 Herr K, Anderson G. The Action Research Dissertation: A Guide for Students and Faculty. Thousand Oaks, California2005. Available from: http://methods.sagepub.com/book/the-action-research-dissertation. 30 Greenwood D, Levin M. Introduction to Action Research. Thousand Oaks, California2007. Available from: http://methods.sagepub.com/book/introduction-to-action-research. 31 Van Der Pligt J. KW, Van Harreveld F. Bestraffen, belonen, beïnvloeden. Een gedragswetenschappelijk perspectief op handhaving. . Den Haag: Boom Juridische uitgevers; 2007. 32 Pol B. SCE. Nieuwe aanpak in overheidscommunicatie. Tweede herziene druk ed. Bussum: Coutinho; 2013. 33 Lindenberg S, Steg L. Normative, Gain and Hedonic Goal Frames Guiding Environmental Behavior. Journal of Social Issues 2007; 63: 117-37. 34 Erasmus V, Brouwer W, Van Beeck EF et al. A qualitative exploration of reasons for poor hand hygiene among hospital workers: lack of positive role models and of convincing evidence that hand hygiene prevents cross-infection. Infect Control Hosp Epidemiol 2009; 30: 415-9.
59 If there’s something you really want to believe, that’s what you should question the most - Penn Jillete CHAPTER 4 Nudging to improve hand hygiene 4
Martine G. Caris Heleen A. Labuschagne Mireille Dekker Mark H.H. Kramer Michiel A. van Agtmael Christina M.J.E. Vandenbroucke-Grauls
Journal of Hospital Infection, April 2018 62 Chapter 4 s o achlbsd ad u. hn plig ugs o hne eaiu, t is important toidentifytherightnudgeforaudience. it behaviour, change to nudges applying When rub. hand alcohol-based of increaseuse to measure inexpensive easy, an provide could posters, as displayed and CONCLUSION dispensers withoutadjacentnudgesdidnotincrease. of Use (1.3-3.8)). 2.2 B ward (1.1-2.6); 1.7 A ward 1: [poster wards both on rounds risk 1.6 (95% confidence interval 1.2-2.2); poster 2: 1.7 (1.2-2.5)] and during doctor’s displayed next to dispensers increased their overall use on one ward [poster 1: relative FINDINGS rub, measured withelectronic dispensers. two on trial before-after controlled hospital wards, a to assess the effect of these conducted nudges on the use of alcohol then based hand We audience. target the throughcross-sectionalamongthese a survey tested and biases, cognitive described METHODS the useofalcohol-basedhandrub. AIM cognitive biasesandthussupporthandhygiene interventions. address to measure inexpensive implemented, easily an provide could behaviour’, desired encourage to push friendly ‘a Nudging, non-compliance. induce may these as such biases Cognitive negligible. hygiene hand poor through infections causing of workers odds the healthcare consider will they When infections, healthcare-associated challenging. encounter seldom is compliance improving but infections, BACKGROUND ABSTRACT To investigate whether behavioural nudges, displayed as posters, can increase can posters, as displayed nudges, behavioural whether Toinvestigate e eeoe nde bsd n sseai rve o previously of review systematic a on based nudges developed We Poisson regression analyses adjusted for workload showed that nudges that showed workload for adjusted analyses regression Poisson Nudges based on cognitive biases that play a role in hand hygiene, hand in role a play that biases cognitive on based Nudges ad yin i prmut o rvn healthcare-associated prevent to paramount is hygiene Hand INTRODUCTION
Healthcare-associated infections pose a threat to patient safety. Although hand hygiene is the most effective strategy to prevent these infections, adherence to hand hygiene guidelines is poor. 1-3 To improve adherence, many methods have been applied, but structural improvement is challenging. 4 Measures to support the effect of interventions are therefore essential.
One strategy that may be effective, but is not yet commonly applied in healthcare, is nudging: a friendly push to encourage desired behaviour. Nudging is widely used to stimulate healthy behaviour, such as smoking cessation and healthy food choices. 5,6 4 Nudging of healthcare workers has only recently been addressed in a few studies, in which various kinds of nudges proved successful in influencing physician prescribing behaviour.7-10 Although the exact mechanism has not been clarified, it has been suggested that nudges influence behaviour by addressing cognitive biases underlying non-compliance.11 Cognitive biases are often caused by ‘heuristics’. In social sciences, heuristics are defined as decisional shortcuts which can be useful, as they help us to quickly make judgements or decisions. However, when heuristics lead to cognitive biases, they can confound our judgement and thus influence our behaviour.
In medical decision making, several cognitive biases and underlying heuristics have been proposed to play a role. 12,13 One example is the ‘availability heuristic’, which describes how we assess the probability of an event by the ease with which we can recall it: the easier an event is to recall, the more likely we consider it to occur. Conversely, this means that if prevalence of healthcare-associated infections is low, healthcare workers are inclined to believe that chances of transmitting an infection through lack of hand hygiene are also low, thus leading to non-compliance. 14 Heuristics such as these also play a role in influenza vaccination among healthcare workers, and nudges specifically designed to target these heuristics were shown to increase vaccine uptake.11 Although evidence is scarce, research indicates that behavioural nudges could also be useful to improve hand hygiene, both in school children and healthcare workers.15,16
Nudging could provide an easily implemented, inexpensive measure to support hand hygiene interventions. In this study, heuristics and cognitive biases that could play a role in hand hygiene non-compliance were reviewed. We then developed a set of nudges addressing these biases and assessed their effect on the use of alcohol-based hand rub in our hospital. 63 64 Chapter 4 use ofadjectives,withamaximum ofthree. (table II), with a maximum of five. Responses to slogans were only assigned points for adjectives negative and positive of use and hygiene, hand with link their for points assigned were images to Responses counterproductive. be may attitudes negative to evoke a reaction. Nudges generating a positive attitude are more effective, merely the therefore activity; image or desiredslogan needed to evoke a link with hand hygiene. the In addition, nudges need of reminder a be to needs nudge a behaviour, changing in effective be to order In nudge. images a as the value their assess to to slogans, and responses evaluated independently HL) and (MC researchers Two images andeightsloganswere askedopen-endedquestions onwhattheseevoked. 10 with presented were Respondents USA). California, Mateo, (San Inc. throughSurveyMonkey distributed was survey The medicine. internal mostly doctors, 27 and wards, clinical all from nurses 60 students, 110 of sample convenience a to sent was survey A slogans (in nudge correct hand hygiene behaviour. These were used as input for the images and to important be therefore might which and hygiene, hand on decisions in relevant be could that consider.types to 14 types Tablethe additional lists no I revealed This specifically.hygiene hand in and control, infection in biases cognitive on studies for hand hygiene. In addition, we systematically searched PubMed, CINAHL and PsycINFO which choices are presented, which does not apply to the yes/no decision to performin order the to applied others two and patients, diagnosing in recognition pattern to applied 27 irrelevant: considered were these of Most hygiene. hand to relevance that heuristics and biases making. decision medical in role a cognitive play could of types 43 proposed have studies Previous Nudges hand rub,measured withelectronic dispensers. alcohol-based of use the on effect their assess to wards hospital two on displayed designer graphic a audience, target devised posters the with the two highest scoring among slogans and images. These posters survey were a on Based slogans. and images using addressed be could biases these how assessed then was It conducted. was hygienenon-compliance hand underlying biases cognitive possible literatureon theof review systematic A trial. before-aftercontrolled a with survey cross-sectional In this university medical centre, a mixed-methods study was performed, combining a Design andsetting METHODS supplementary material ). 11-13 We evaluated these types for their for types these evaluated We Heuristic/cognitive bias Meaning Relevance to hand hygiene Affect heuristic12 Behaviour is influenced by the emotional Hand hygiene can be associated with both positive response (the affect) a stimulus evokes, which affect (i.e. being clean, providing safe care) and influences the way risks and benefits are negative affect (i.e. it is a nuisance, thought of as perceived. If an activity or stimulus evokes unnecessary, or it irritates the skin) positive feelings, risks are perceived as low while benefits are considered high, and vice versa Impact bias12 People tend to overestimate the long-term ‘If we always perform hand hygiene, there will be impact of events no more time left for actual care’ Optimism bias11,12 People have a tendency to believe that particular ‘We never see problems with healthcare- health risks are greater for other people than associated infections on our ward’ themselves Present bias11 People have a tendency to value costs and Short-term risk of more work and skin irritation benefits today higher than costs and benefits in can weigh more heavily than reducing healthcare- 4 the future associated infections Availability heuristic11-13 People assess the probability of an event by the ‘Hand hygiene compliance is low and we just had ease with which they can recall such an episode. an outbreak’ The occurrence is considered more likely if an episode is easy to recall ‘I don’t always wash my hands and I have never caused an infection’ Confirmation bias12,13 People have a tendency to see evidence in favour See availability heuristic of their beliefs and to ignore evidence for the opposite Default bias or status quo Disadvantages of leaving the status quo Increasing hand hygiene performance requires bias12 outweigh the corresponding advantages17 leaving the status quo Bandwagon effect12 The probability of an individual adopting an If everyone cleans their hands, more people will activity or behaviour increases when more and vice versa people have already done so Ambiguity aversion11,12 The tendency to prefer a known risk to an Balancing risks of skin irritation (easily visible) and unknown risk healthcare-associated infection (hard to see). Commission bias12,13 People have the “tendency toward action rather Performing hand hygiene is an action than inaction”13 Loss/gain framing bias or Avoiding losses is a more powerful driver of If I always perform hand hygiene, I will get dry loss aversion bias12,18 decisions than the corresponding gains skin. Besides, infections can be easily treated with antibiotics’ Omission bias11-13 A potentially harmful inaction (omission) is Omitting hand hygiene to avoid skin irritation usually preferred to a possibly less harmful action Frequency/percentage Risks are perceived as higher when displayed as Rates of healthcare-associated infections can be framing effect12 frequencies expressed as frequencies Relative risk bias12 People are more likely to choose an activity when The effect of proper hand hygiene on reducing presented with relative risk than when the same healthcare-associated infections can be expressed information is described as an absolute risk as relative risk reduction instead of absolute risk reduction
TABLE 1 Overview of heuristics and cognitive biases that could play a role in hand hygiene behaviour
65 66 Chapter 4 ek aeie esrmn, h pses ee eunily ipae a te wards’ entrance, for the two weeks each. at The sequence for each displayed ward was assigned sequentially randomly. were We posters the measurement, baseline week two- a After activation. one as recordedwere uses consecutive pressed; consecutively dispensers These was handle the same. times of number the and activated were they time exact the the recorded functioned and looked and previous, the dispensers as (shared) non-electronic location different same the in at two installed were other dispensers the The rooms. entrance, patient the at one ward: each on were Germany) installed Issum, Co.KG, & GmbH Hygiene-Technik Monitoring Ophardt Hygiene (OHMS), (Ophardt System dispensers rub hand alcohol-based electronic Three on theWorld HealthOrganization’s ‘5moments forhandhygiene’). averagesimilar hygienehand basedratesobservation, compliance overt with (50-60% and days), nine to six stay: of length (average patients of turnover medium-high had ward,admissions bothacute wardan one was Although beds. 24 had and specialties, surgical and medical both of patients adult with wards (ICU) unit care non-intensive clinical, were both characteristics: similar their on and use, current their with interfere Two hospital wards were selected, based on the location of their dispensers, so as to not Alcohol-based handrub TABLE 2 (IBM SPSSInc.,Chicago,IL,USA). Windows for 22.0 SPSS using otherwise), or nurses (i.e. professionrespondent’s the for and questionnaire hygiene hand the on score overall for adjusting images, and supplementary material Erasmus by and could therefore affect the response to the images and slogans. The questionnaire personnel, healthcare of behaviour hygiene hand influence to described been different have for different be to shown workers. been healthcare have hygiene hand poor for Reasons use ofwords handhygiene, suchas handwashing linkedDirectly use ofwords contagious, suchas transfer ofbacteria linkedIndirectly no useofany words related to handhygiene No link Link withhandhygiene Categorization ofresponses toimagesandslogansintheonlinesurvey t al et ws sd o ses hs fcos tasae qetonie in questionnaire (translated factors these assess to used was . 14,19 In addition, factors such as knowledge and risk perception risk and knowledge as such factors addition, In ). 20 With linear regression, we assessed scores of the slogans use of adjectives such as good, suchas use ofadjectives nice Positive annoying, funny” “Somewhat somewhat positiveuse ofboth andnegative adjectives Positive andnegative use ofneitherpositive nornegative adjectives Neutral annoying, suchas use ofadjectives exaggerated Negative Reaction 0 Points 3 2 1 used a patient-based approach to measure workload (i.e. nurse:patient ratio), defined as number of FTE (full-time equivalent) per admission day, which we obtained from our hospital’s business intelligence department.
We analysed changes in the number of activations through Poisson regression analyses, adjusting for workload and correcting for correlated observations through stratification per dispenser, with STATA/SE 14.1 for Windows (StataCorp LP, College Station, TX, USA).
RESULTS 4 Nudges Overall survey response rate was 26%; responders were 19 medical students, 15 physicians (1 haematology, 1 infectious diseases, 1 psychiatry, 12 internal medicine), and 18 nurses (accident and emergency, gastroenterology, ICU, internal medicine, nephrology, neurology, obstetrics and gynaecology, paediatrics, psychiatry, pulmonology, surgery). The two highest-scoring images had mean scores of 3.1 and 3.0. The two highest-scoring slogans had mean scores of 2.6 and 2.4. These scores were not influenced by profession, or by score on the hand hygiene questionnaire. The highest-scoring image was specifically mentioned in response to the highest- scoring slogan, as was the second-highest-scoring image in response to the second- highest-scoring slogan. These two were therefore paired on the posters (figure 1).
FIGURE 1 Nudges, developed according to survey responses. Poster 1 (left): ‘Half of all healthcare workers perform well in hand hygiene. Which category do you belong to?’ Poster 2: ‘40% increase in hand hygiene, 40% decrease in healthcare-associated infections’
67 68 Chapter 4 (95% CI0.91-2.42); •••,RR2.20(95%CI1.28-3.78) 1.49 RR ••, 1.09-2.55); CI (95% 1.67 RR •, 1.31-3.33); CI (95% 2.09 RR *, Interval): Confidence CI, Risk; Relative RR, workload; for adjusted analyses, regression Poisson of (results baseline to compared poster the of display during rounds, doctor’s during activations of number the indicate Symbols infections’). less hygiene,(‘Morehand 2 and to?’) belong you do category (‘Which 1 posters of display during and baseline 2 FIGURE
Number of activations of the entrance dispensers on ward A en B per hour of the day,during the of hour per B en A ward on dispensers entrance the of activations of Number Alcohol-based hand rub The six dispensers together were used 2842 times. Both posters increased the overall use of the entrance dispenser on ward B [poster 1: relative risk 1.61 (95% confidence interval 1.18-2.20), poster 2: 1.72 (1.17-2.53)] but not of the entrance dispenser on ward A [poster 1: 1.04 (0.79-1.38), poster 2: 1.07 (0.80-1.42)]. There was no effect of the entrance posters on the use of dispensers inside patient rooms. During the intervention periods, use of the entrance dispensers showed peaks between 9 and 11 (figure 1), coinciding with the doctors’ morning rounds. On ward B, a second peak between 16 and 18 coincided with a ward-specific afternoon doctors’ round. 4 DISCUSSION
Our study indicates that nudges, based on cognitive biases and displayed as posters, can increase the use of alcohol-based hand rub when shown next to dispensers. One of the nudges had an effect on both wards, increasing the use of adjacent dispensers during specific times of the day, whereas the other nudge increased overall use of the entrance dispenser on one ward. At the same time, there was no change in use of the dispensers where no posters were displayed.
Although our sample is small, these findings are in line with the few studies that have used nudges to influence healthcare workers’ behaviour. Meeker and colleagues designed a nudge that appealed to the power of public commitment, by asking general practitioners to sign a letter of commitment to appropriate use of antibiotics. Prominent display of this letter in their examination room led to a 20% absolute reduction in inappropriate prescribing. 7 Tannenbaum and colleagues nudged appropriate prescribing by rearranging treatment options in an electronic health record, which led to a 12% absolute reduction in aggressive treatment. 10 The same approach was shown effective in improving ventilation and appropriate prescribing of mouthwash in ICU patients. 9,21 In a study specifically addressing hand hygiene, nudges were shown to increase hand washing among school children from 4% to 74%.15 These studies all show how, by targeting certain aspects of ‘choice architecture’, seemingly small interventions can influence behaviour.
Other studies have shown that posters solely serving as a reminder or educational message are not effective, and that message-framing on hand hygiene posters is crucial to achieve an effect. 18,22 Dubov and Phung specifically addressed cognitive biases underlying low rates of influenza vaccination among healthcare workers, and showed how nudges targeting these biases can increase vaccine uptake. 11 This 69 70 Chapter 4 research. The effect of changes in the environment may be subject to the novelty the to subject be may environment the in changes of effect The research. further warrants that effect interesting an see did we study,explorative small, this withHowever, possible. not was Unfortunately,this results. our strengthened have More dispensers with adjacent posters and a wash-out period between posters would We only had six electronic dispensers at our disposal, for a limited time of six weeks. compliance.hygiene hand on conclusions draw cannot therefore We use. rub hand collected data on use of the dispensers, not on the appropriateness of alcohol-based not were participants study aware thereforeof being monitored, eliminating response remotely; bias. It should be noted collected that we only was use their on data dispensers, electronic the With results. our strengthen might background, diverse more a with sample, larger a among Surveys low. were rates response addition, In medicine. internal in worked doctors responding all almost units, different many on we Although effect. evaluated the nudges among the target audience and morethe responding nurses worked had have could images higher-scoring other, Perhaps nudges. Scores for the slogans were high, but scores for the images were moderate. posters. ready-made nurses, doctors, and students), which has been proposed as more effective than using (i.e. end-users expected the from input with designed were nudges the addition, In interventions. other to use of be may overview this literature hygiene; hand to thorough applicability a performed their for these Weassessed and non-compliance underlying biases limitations. cognitive on review and strengths has study Our is registered alongwiththeuseofadispenser, couldshedlightonthishypothesis. profession user’s the which in or nurses, or doctors address specifically to designed shown to be different for doctors and nurses. that the nudge appealed more to doctors. Reasons for poor hand hygiene have been both on indicate could which effect rounds, doctor’s during increased an mainly However,wards.use had and biases, risk relative and aversion loss the to appealed infections’) less hygiene, hand (‘moreacceptability. 2 enhance Poster perhaps could who is nudged’. the acceptability of a nudge depends on ‘the nature of the nudge, who nudges, and models. role of absence or presence the or hygiene hand to due be could This differences B. between the ward wards we on did not effect account for, an such as showed ward culture only regarding and effect, bandwagon the to appealed to’) belong you do category (‘which 1 Poster effects. different had We displayed two different nudges, appealing to different cognitive biases, and these and cognitivebiasesunderlyingnon-compliance. strengthens the idea that the effect of nudges possibly relies on addressing heuristics 23 Further refined nudges, based on cognitive biases at the ward level, 24 We selected the highest-scoring images and slogans for our for slogans and images highest-scoring the selected We 14,19 Future studies, in which nudges are 19 As previously described, previously As effect; studies with longer follow-up are needed to assess whether the effect of nudges is sustained.
There is, of course, no easy solution to increase hand hygiene compliance, and multi- faceted intervention strategies are preferred. Nudging should not be considered a stand-alone intervention, but rather a supportive measure to optimize intervention strategies. Our study indicates that displaying nudges next to dispensers could be a useful, inexpensive measure to enhance the use of alcohol-based hand rub.
SUPPLEMENTARY MATERIAL 4
(available online) Appendix A. Images presented in online survey Appendix B. Slogans presented in online survey Appendix C. Questionnaire on Hand Hygiene (translated from Dutch)
71 72 Chapter 4 4 3 2 1 REFERENCES 12 11 10 9 8 7 6 5 20 19 18 17 16 15 14 13 21 hygiene improvement strategies: abehavioural approach. guidelines inhospitalcare. 21 initiative infections:results onhealthcare-associated ofaninterrupted timeseries. the role ofimproved practices. review usingasystematic search strategy. 2530-5. order study. set:results ofavignette-based 382-8. a before evaluation and after prescribing of an electronic template care. in critical improve prescribing. randomized clinicaltrial. positional influences on food choice. Open analyses. evaluationinterventions: through time-series intervention the ICU with two nudge-based Rotterdam, The Erasmus Netherlands: MC;2012. a teaching hospitalin Toronto, Canada. Hospital Infection York: Foundation/Cambridge RussellSage University Press; 2000.p. 159-70. choices, values, D, andframes. Kahneman In: Tversky A,editors. Choices, values, andframes. 159.New Control JInfect Am Res Public Health Communication: Students School inBangladesh. Nudging Handwashing amongPrimary prevents cross-infection. among hospitalworkers: lackofpositive role modelsandofconvincing evidence that handhygiene Acad Emerg Med Huis A, Van Achterberg T, BruinM,Grol De R,Schoonhoven L,HulscherM.Asystematic review ofhand Erasmus V, Daha TJ, BrugH JA, Ptak RA, KB, Lasky HomaKA, TaylorKirkland ofahospital-wide handhygiene EA,SplaineME. Impact Pittet D, Allegranzi B, H Sax Blumenthal-Barby JS, Krieger H.CognitiveBlumenthal-Barby a critical JS,Krieger in medical decision making: biases and heuristics Dubov A,Phung C.Nudgesormandates? flu vaccination.The ethicsofmandatory Tannenbaum D, JN,Persell Doctor SD Bourdeaux CP, Davies KJ, Thomas MJ, JS,Gould Bewley TH. Using ‘nudge’ for principles order setdesign: AJ. CR,Kaasch Katchanov J, S,Mackenzie Kluge D,Meeker Knight FriedbergTK, MW Bucher T, Collins ME C,Rollo Sunstein CR.Nudging smokers. Erasmus VE. Compliance to HandHygiene GuidelinesinHospitalCare -Astepwise behavioural approach. Jang JH, D Wu S,Kirzner Jenner EA,JonesF, Fletcher B, L,ScottGM.Handhygiene Miller posters: sellingthemessage. D.Kahneman KJL, Thaler, R.H.Anomalies: The endowment effect, loss aversion, andstatus quobias, in Kwok YL, Juergens CP, Mclaws ML.Automated handhygiene auditingwithandwithoutanintervention. Dreibelbis R, KroegerA, Hossain K, BehaviorVenkatesh Change without Behavior Change PK. M, Ram Erasmus V,Brouwer W,EF Beeck Van P.Croskerry cognitive Achieving inclinicaldecisionmaking: strategies quality ofbias. anddetection Bourdeaux CP, Thomas MJ, Gould TH : 1019-26. 2016; 6 : e010129. 2002; 2016; 2005; 2016; Infection 9 13 59 etal : 1184-204. 44 JAMA Intern Med Infect ControlInfect HospEpidemiol . : 77-82. etal Infect ControlInfect HospEpidemiol : 1475-80. et al . Focus group studyofhandhygiene amonghealthcare practice workers in etal 2016. The Lancet Diseases Infectious N EnglJMed . Evidence-based model for . hand Evidence-based transmission patient during care and . Nudging consumers towards healthier choices: asystematic review of . Systematic review ofstudiesoncompliance withhandhygiene etal etal etal Br JNutr etal Infect ControlInfect HospEpidemiol . Nudging physician the prescription decisionsby partitioning 2014; . . Increasingcompliance withlow tidalvolume ventilation in Med Decis Making Med Decis A qualitative exploration ofreasons for poorhandhygiene J Gen InternJ Gen Med . 2015; Nudging guideline-concordant antibiotic prescribing: aNudging guideline-concordant 2016; 174 “Nudging” inmicrobiological astrategy reports: to 372 115 : 425-31. 2009; : 2150-1. 2010; : 2252-63. Implement Sci 2015; 2015; 2006; 30 31 : 415-9. : 283-94. 30 35 6 : 641-52. 2010; : 298-304. : 539-57. 2012; 31 : 144-50. 7 : 92. BMJ Qual Saf BMJ Qual BMJ Qual Saf BMJ Qual Vaccine Int JEnviron 2015; Journal ofJournal 2014; 2012; BMJ 23 33 : : 22 Morse L, Mcdonald M. Failure of a poster-based educational programme to improve compliance with peripheral venous catheter care in a tertiary hospital. A clinical audit. Journal of Hospital Infection 2009; 72: 221-6. 23 Lucke J. Context is all important in investigating attitudes: acceptability depends on the nature of the nudge, who nudges, and who is nudged. Am J Bioeth 2013; 13: 24-5. 24 Seto WH, Yuen SW, Cheung CW, Ching PT, Cowling BJ, Pittet D. Hand hygiene promotion and the participation of infection control link nurses: an effective innovation to overcome campaign fatigue.Am J Infect Control 2013; 41: 1281-3.
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EDUCATION ON ANTIBIOTIC PRESCRIBING I hear and I forget. I see and I remember. I do and I understand - Chinese proverb CHAPTER 5 Improving antibiotic prescribing skills in medical students: the effect of 5 e-learning after six months
Jonne J. Sikkens Martine G. Caris Tim Schutte Mark H.H. Kramer Jelle Tichelaar Michiel A. van Agtmael
Journal of Antimicrobial Chemotherapy, August 2018 78 Chapter 5 tdns promne f n niirba teaetc oslain n situation simulating clinicalpractice 6monthslater. a in consultation therapeutic antimicrobial an of performance students’ CONCLUSIONS +0.31 and+0.51,respectively). +0.31, group (differences the intervention in higher significantly also were (1–10) overall,OSCE grades1.7–20.0). choice CI drug 95% and 5.9, knowledge OR (+11%, pass percentage was 86% in the control group versus 97% in the intervention group control group. E-learning participation in the intervention group was 81%. The OSCE RESULTS choice andoverall scores. We usedpropensity scores tocreate equalcomparisons. not was e-learning the implemented. Main outcomes were the OSCE pass percentage when and knowledge, drug period a from students of group control a created We once. only OSCE the did student each passed, they If prescribing. postgraduate simulating at aimed (OSCE) examination clinical structured objective disease-based course during a 6 week period. Six months later, all students underwent an infectious a Dutch university. The e-learning was temporarily implemented as a non-compulsory effects of a short interactive e-learning course among fourth year medical students in METHODS yet unknown. its but as is students solution, medical in behaviour time-efficient prescribing long-term changing in potentially effectiveness a is (e-learning) use learning The electronic curriculum. of medical the in stewardship antimicrobial of implementation the in problem important an as time of lack cite often teachers study,but medical BACKGROUND ABSTRACT We included 71 students in the intervention group and 285 students in the We performed a prospective controlled intervention study of the long-term Antimicrobial prescribing behaviour is first established during established first is behaviour prescribing Antimicrobial E-learning during a limited period can significantly improve medicalsignificantly can period limited a during E-learning INTRODUCTION
Education is an essential pillar of antimicrobial stewardship. 1 The basis for professional behaviour is laid during the first years of medical study. Interventions to promote prudent antimicrobial prescribing should therefore increasingly focus on undergraduates, rather than on postgraduates only. 2 A recent survey revealed that European medical teachers feel the subject of prudent antimicrobial prescribing should be prioritized. However, teachers cited time restriction as the most important obstacle.3 Electronic/internet- based learning (e-learning) offers an interesting potential solution to this problem because, after creation, large groups of students can participate with a relatively small investment of time and cost. 4,5
E-learning can be equally effective as an alternative education method in improving 5 patient-related outcomes and influencing healthcare professionals. 6 E-learning has shown positive effects on drug prescribing, but more evidence regarding behaviour change in practice and long-term retention (>12weeks) is needed. 4,7-9 Educational interventions on antimicrobial prescribing have shown effectiveness, 10-14 but effects could not always be isolated from other intervention effects. The question remains whether a short period of e-learning can improve antimicrobial prescribing skills and behaviour in undergraduates in the long term.
We developed a problem-based, interactive e-learning module on antimicrobial prescribing for fourth year medical students, con- forming to scientific recommendations. 2,15,16 We tested the e-learning’s long-term (after 6 months) effectiveness in improving student competence in performing a therapeutic infectious dis- ease consultation in a simulated patient situation.
METHODS
Design Prospective controlled intervention study of long-term effects, combined with randomized controlled intervention study of short-term effects (knowledge only).
Population Medical students at the VU University Medical Centre Amsterdam, The Netherlands.
79 80 Chapter 5 efrac bsd n sadrie soe ytm nldn sb crs o drug choice andknowledge.Examiners were blindedtogroup allocation. for scores sub including system score standardized a on based performance a written prescription for an infectious disease case. Students were scored on overall literature.previous and methods Supplementary with recommendations from literature including use of a patient actor; (OSCE) aimed examination to simulate clinical prescribing behaviour in structured clinical practice objective and was set The up concordant experts. several by each, validated questions multiple-choice 57 comprised tests knowledge antimicrobial The Measurements SurveyMonkey, http://www.surveymonkey.com). education in the curriculum. The e-learning included an evaluation survey (created in WHO’s guide to good the prescribing,17 similar on to the based paradigm of was the pharmacotherapyand cases clinical eight comprised again), link click and free for (in Dutch, to access: click https://www.medischonderwijs.nl?LESSONID=1693, register The e-learning module was built into the Dutch e-learning portal MedischOnderwijs.nl E-learning module board review (NVMO-ERB). ethical educational national the by approved was study study The each group. for process inclusion full the shows supplement) (see S1 Figure 2012. Septemberand 2009 September between curriculum the of year fourth their started had who 1 group control or group intervention the in included not students all of We created another control group (control group 2) for the long-term effect analysis (i.e. e-learning e-learning contamination), control group 1wasexcludedfrom thelong-termanalysis. the to the exposure of to risk potential access the to given Owing werepost-test. the 1 after group control in students education, to access equal student each allow To post-test. knowledge antimicrobial the before shortly ended access E-learning completion. e-learning <80% of case the in e-mails reminder three to up and e-learning the to link e-mail an received students group E-learning 1). group (control e-learning no or weeks 6 for access e-learning direct an antimicrobial knowledge pre-test. Afterwards, students were randomized to either informed about werethe e-learning programme during an education lecture and asked to complete Students 2012. August and 2011 September between curriculum medical the of six) of (out year fourth the in introduced was module e-learning The Participant selectionandstudygroups 19
The final product of the exam was exam the of product final The 18 also see the Outcomes Primary outcomes were based on evaluation of long-term e-learning effects and comprised overall drug choice and knowledge OSCE scores (all grades 1–10, higher scores indicating a better performance) and OSCE pass percentage (overall score >5.5). Secondary outcomes were the short-term effect of e-learning on knowledge by comparing scores on the second antimicrobial knowledge test while controlling for scores on the first test; and students’ evaluation of the e-learning.
Statistical analysis We used the intention-to-treat principle to define intervention status. We determined the effect of the intervention by comparing outcomes between the intervention group and control group 1 for short-term effects and control group 2 for long- term effects. Univariate linear or logistic regression was used for all comparisons. 5 We used propensity scores to control for confounding effects of students’ prior level, case differences and use of different examiners to allow valid comparisons. We also performed an as-treated analysis. We considered p<0.05 significant. See the Supplementary methods for more details on the medical curriculum, outcome measures and statistics.
RESULTS
Inclusion We included 56 students in control group 1, 68 students in the e- learning group for the short-term comparison, 285 students in control group 2 and 71 students in the e-learning group for the long-term comparison. Details of inclusion are shown in Figure S1 (see supplement). Baseline characteristics of study groups are shown in Table 1.
E-learning effects Students in the e-learning group scored significantly higher on all continuous outcomes compared with control group students (Figure 1). OSCE pass percentage was also significantly higher for e-learning group students compared with control group students (97% versus 86%, n=346, OR 5.90, 95% CI 1.74–20.01, p=0.004). Effect sizes increased when using an as-treated approach (Figure S2, see supplement).
81 82 Chapter 5 TABLE 1 severe insecuritydecreased from 74%to37%(p=0.002) and subsequent to the e-learning, the percentage of students indicating insecurity or to prior practice clinical in therapy antimicrobial prescribing in confidence their on 77% rated it as 7.4),entirely relevant, but was 55% rated it 10 as too extensive. When to questioned 1 from score (average instructive as e-learning the rated Students Evaluation survey 75 to 100%completed (%) 25 to 75%completed (%) up to 25%completed (%) ever opened(%) E-learning Average score onpharmacotherapy exam inprioryear Age inyears (range) Female (%) N Long-term analysis effects 75 to 100%completed (%) 25 to 75%completed (%) up to 25%completed (%) ever opened(%) E-learning Average score onpharmacotherapy exam inprioryear Average score onantimicrobial test 1(range) Age inyears (range) Female (%) N analysis effects Short-term Baseline characteristics ofstudygroups 11 (15) 58 (82) 6.7 (2.8-9.1) 23.5 (20-38) 52 (73) 71 E-learning group 28 (41) 17 (25) 11 (16) 56 (82) 6.7 (3.9-9.1) 4.0 (1.7-7.4) 23.5 (20-38) 49 (72) 68 E-learning group 29 (41) 18 (25) 23.4 (21-48) 43 (77) 56 Control group 1 - - - - 6.8 (2.5-9.6) 23.1 (20-41) 200 (70) 285 Control group 2 - - - - 6.4 (2.5-8.8) 4.0 (1.7-6.0) 23.5 (20-48) 92 (74) 124 Total - - - - 6.8 (2.5-9.6) 23.2 (20-41) 252 (71) 356 Total - - - - 6.6 (2.5-9.1) 4.0 (1.7-7.4) FIGURE 1 Continuous outcomes from students in the e-learning group compared with control group students. The possible grade range was 1–10, with higher scores indicating a better performance
DISCUSSION 5
This prospective controlled intervention study showed that access to e-learning for a limited time period significantly improved medical students’ long-term antimicrobial drug choice, antimicrobial knowledge and overall performance during an antimicrobial therapeutic consultation with a patient actor. In order to shape future antimicrobial prescriber behaviour, it is very important to identify resource-effective tools that can improve undergraduates’ prescribing competence, rather than at a later stage when physicians have already begun clinical practice. 2 Our results suggest that e-learning may be just that. Although the main results on the continuous outcomes were relatively small (0.31–0.51 difference on a 1–10 scale; Figure 1), results on the pass percentage (11% difference) suggest that the intervention made a difference where it matters: among students whose prescribing competence balanced around the fail/ pass level. The e-learning was rated positively by students and increased their self- rated confidence in prescribing.
Our study is unique in that it estimates intervention impact by assessing students’ behaviour in a situation that simulates prescribing in clinical practice, using an approach recommended in literature.18 It is one of very few studies to evaluate the long-term impact (>12weeks) of a temporary educational intervention on antimicrobial prescribing.11 The design of the study and the availability of prior student grades allowed us to create optimal equal comparisons between intervention and control groups. The inclusion of the short-term effect analysis made it possible to assess direct impact on knowledge and a potential fade of knowledge retention over time.
83 84 Chapter 5 mrv mdcl tdns ln-em niirba du coc, antimicrobial situation simulatingclinicalpractice. choice, drug antimicrobial knowledge and overall performance of an antimicrobial therapeutic long-term consultation in a students’ medical improve significantly can period time limited a during access e-learning that shown have We instance inpostgraduate training, maybeimportant. for e-learning, the Repeating practice. in prescribing start they when present be will effecte-learning the of much how unclear is it OSCE, the after years 2 additional an for study to had who students included study our Finally,because level. knowledge the student of measurement imperfect an caused have may This difficult. too been have of results The effects. may test the suggesting groups, across examiner low were post-test knowledge antimicrobial for adjustment and approach assessment structured a using by diminish to aimed we which results, inconsistent to lead can We need to address some limitations. Assessment of students’ skills is subjective and have supportedlong-termretention oflearningeffects. may curriculum the and e-learning between interaction the students, group control paradigm.same the using education pharmacotherapywith curriculum the in Moreover,implemented was e-learning the which is a method known to improve therapeutic competence of medical students. its exercisesfeedback; and enhanced architecture; have problem-based its may include that factors certain attempts. replicationfuture for mention to important are which effectiveness, comprised used e-learning The is effect’ ‘true higher, aswouldbeexpected. the suggest results as-treated The is perfect. education be to non-compulsory expected seldom in participation as practice, in impact intervention reflects partially.This only or all at e-learning the access not did either students of was impact intervention considerable percentage a group, although whole the averaged for when significant that show analyses intention-to-treat the of results The 16 and the use of the WHO six step plan to good prescribing,good to plan step six WHO the of use the and 20 Although the curriculum was identical for thefor identical was curriculum the Although 2,15 h icuin f neatv elements, interactive of inclusion the 5 They 17,20
SUPPLEMENTARY MATERIAL
METHODS
Medical curriculum The medical curriculum in which the study was performed had a bachelor (three years) and masters (three years) structure, in which the bachelor comprised mostly theoretical education in the faculty, combined with a few short internships. The bachelor included a course on infectious diseases and microbiology, including antimicrobial chemotherapy. The master comprised a series of internships inside and outside the hospital, combined with a two-month science internship, and three months of free choice education. Every three weeks, a group of around 20 students started with the fourth year of the Master. Because we wanted to include each 5 student at the exact same time point in their study, we followed this group structure in our inclusion. E-learning participation was voluntary and unlinked to study credits or grades. All interventions and measurements were part of the regular curriculum at the time of the study. Students did not have experience of prescribing antibiotics under supervision at time of inclusion.
Randomisation Randomisation was performed using the random number function in the SPSS version 20 software package, using a 55:45 ratio in favour of the intervention group, in order to account for student dropout in the long term analysis.
Antimicrobial knowledge tests Both antimicrobial knowledge tests comprised 57 unique multiple choice questions. Difficulty was targeted at medical study end terms. The quality and difficulty of the tests were validated by two infectious disease specialists, a clinical microbiologist, a clinical pharmacologist, a general practitioner and a medical examination specialist.
OSCE The OSCE took 15 minutes, and was observed and assessed by an examiner from the pharmacotherapy department. The OSCE comprised three parts: 1. case preparation, 2. consultation, in which the student performed a therapeutic consultation with a patient-actor, discussing the therapeutic options, therapy choice, side effects and follow-up instructions; and 3. structured discussion with the examiner on pre-defined topics. During the OSCE (discussion part excluded), use of any information resource (e.g. internet) was allowed. Prior to the OSCE, students were informed that the case would deal with one of 19 diagnoses. Only a minority of these diagnoses were infectious 85 86 Chapter 5 FIGURE S1 e-learning group:1 e-learning group:9 control group2:12 control group1:10 missing propensity missing propensity Excluded dueto Excluded dueto Control group1 further analysis excluded from data: data: Inclusionandexclusionofparticipants atspecifictimepoints control group1 randomized to 74 students e-learning group:68 control group1:56 Short termef Antimicrobial Antimicrobial E-learning in 165 students curriculum knowledge knowledge analysis: test 1 test 2 randomized to OSCE withinfectiousdiseasecase fects 81 students e-learning e-learning group:71 control group2:285 Long termef analysis: e-learning group:4 control group1:8 10 excluded No show: excluded No show No show fects (control group2) No e-learning in curriculum 439 students OSCE disease case: infectious withnon- 142 diseases but for the current study only infectious disease cases were used. Examiners used a standardised scoring form to score overall performance on the OSCE based on the WHO 6-step, and contained several sub-scores including prescription quality (20% of total score) and knowledge (20% of total score). In the curriculum, exam failure resulted in postponement of continuance of the course until the exam was successfully retried.
Statistical analysis To determine students’ prior level in the long-term analysis we used scores on the pharmacotherapy exam in their third year, a similar exam to the OSCE but without patient-actor consultation. Students’ scores on the antimicrobial knowledge pre-test were used for the short-term analysis. All analyses were performed using Stata version 12 (Stata Corp, College Station, TX, USA). Sample size calculations showed that a minimum sample size of 63 students per group was needed to detect a difference 5 of 0.75 on continuous scores, assuming a baseline of 6.5, and a standard deviation of 1.5. To detect a 10% OSCE pass difference and assuming a 90% baseline, the minimum sample size was 71 students per group. We used a power of 80% and considered p<0.05 as significant. We also performed analyses according to an as- treated model in which intervention group status was determined by actual E-learning participation rather than study group allocation.
87 88 Chapter 5 as ak De o nqa dsrbto bten rus te stetd analyses as-treated the could notbecontrolled fortheeffectofOSCEexaminerorcasedifferences. groups, between distribution unequal to Due mark. pass 100% to due calculated be not could OR 88%, versus 100% completed: 75-100% 100%pass mark; to due calculated be not could OR 85%, versus 100% completed: 25-75% 0-25% completed:87%versus86%,OR1.11,95%,CI1.34-75.02, p=0.89; >25% completed:98%versus86%,OR10.01,95%CI1.34-75.02, p=0.03; were approach as-treated same (E-learning versuscontrol): the to according results percentage pass OSCE As-treated results onOSCEpass-percentages on theextentofE-learningcompletionbystudent. based approachas-treated an using outcomes, continuous for students groupcontrol to comparedgroup S2. FIGURE details. inclusion all for (above) as S1 Figure analysis see missing, the was information from variable propensity excluded be to had students some miscalculation, a to Due Inclusion RESULTS As-treated results on OSCE continuous outcomes. Outcomes from students in the E-learning the in students from Outcomes outcomes. continuous OSCE on results As-treated 75-100% completed 25-75% completed 0-25% completed >25% completed choice drug Long-term 75-100% completed 25-75% completed 0-25% completed >25% completed knowledge Long-term 75-100% completed 25-75% completed 0-25% completed >25% completed Long-term overall 75-100% completed 25-75% completed 0-25% completed >25% completed knowledge Short-term Outcome 15- 050051152 1.5 1 0.5 0 -0.5 -1 -1.5 difference between groups 6.85 7.57 7.45 7.11 7.07 7.27 6.71 7.16 7.18 7.42 7.31 7.24 5.38 4.88 4.26 5.28 E-learning 6.52 6.53 6.53 6.53 6.55 6.55 6.55 6.55 6.75 6.75 6.75 6.75 4.47 4.46 4.52 4.48 Control 0.32 1.04 0.92 0.58 0.52 0.72 0.17 0.61 0.43 0.67 0.56 0.49 0.91 0.43 -0.26 0.80 Δ (-0.43 - 1.07) (0.57 - 1.51) (-0.14 - 1.99) (0.02 - 1.15) (0.17 - 0.88) (0.11 - 1.32) (-0.29 - 0.62) (0.26 - 0.96) (0.07 - 0.79) (0.17 - 1.16) (-0.04 - 1.15) (0.24 - 0.74) (0.29 - 1.52) (-0.35 - 1.21) (-1.10 - 0.58) (0.27 - 1.33) 95% CI 0.40 >0.01 0.09 0.04 >0.01 0.02 0.48 >0.01 0.02 >0.01 0.07 >0.01 >0.01 0.28 0.54 >0.01 p-value 314 303 296 332 314 303 296 332 314 303 296 332 84 73 67 101 N
REFERENCES
1 Dellit TH, Owens RC, Mcgowan JE, Jr. et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44(2): 159-77. 2 Pulcini C, Gyssens IC. How to educate prescribers in antimicrobial stewardship practices. Virulence 2013; 4(2): 192-202. 3 Dyar OJ, Pulcini C, Howard P, Nathwani D, Esgap. European medical students: a first multicentre study of knowledge, attitudes and perceptions of antibiotic prescribing and antibiotic resistance. J Antimicrob Chemother 2014; 69(3): 842-6. 4 Rocha-Pereira N, Lafferty N, Nathwani D. Educating healthcare professionals in antimicrobial stewardship: can online-learning solutions help? J Antimicrob Chemother 2015; 70(12): 3175-7. 5 Gordon M, Chandratilake M, Baker P. Low fidelity, high quality: a model for e-learning. Clin Teach 2013; 10(4): 258-63. 6 Cook DA, Levinson AJ, Garside S, Dupras DM, Erwin PJ, Montori VM. Internet-based learning in the health professions: a meta-analysis. JAMA 2008; 300(10): 1181-96. 5 7 Maxwell S, Mucklow J. e-Learning initiatives to support prescribing. Br J Clin Pharmacol 2012; 74(4): 621-31. 8 Keijsers CJ, Van Doorn AB, Van Kalles A et al. Structured pharmaceutical analysis of the Systematic Tool to Reduce Inappropriate Prescribing is an effective method for final-year medical students to improve polypharmacy skills: a randomized controlled trial. J Am Geriatr Soc 2014; 62(7): 1353-9. 9 Gordon M, Chandratilake M, Baker P. Improved junior paediatric prescribing skills after a short e-learning intervention: a randomised controlled trial. Arch Dis Child 2011; 96(12): 1191-4. 10 Davey P, Marwick CA, Scott CL et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017; 2: CD003543. 11 Perez-Cuevas R, Guiscafre H, Munoz O et al. Improving physician prescribing patterns to treat rhinopharyngitis. Intervention strategies in two health systems of Mexico. Soc Sci Med 1996; 42(8): 1185-94. 12 Irfan N, Brooks A, Mithoowani S, Celetti SJ, Main C, Mertz D. A Controlled Quasi-Experimental Study of an Educational Intervention to Reduce the Unnecessary Use of Antimicrobials For Asymptomatic Bacteriuria. PLoS One 2015; 10(7): e0132071. 13 Razon Y, Ashkenazi S, Cohen A et al. Effect of educational intervention on antibiotic prescription practices for upper respiratory infections in children: a multicentre study. J Antimicrob Chemother 2005; 56(5): 937-40. 14 Zamin MT, Pitre MM, Conly JM. Development of an intravenous-to-oral route conversion program for antimicrobial therapy at a Canadian tertiary care health facility. Ann Pharmacother 1997; 31(5): 564-70. 15 Gould Im VDMJ. Antibiotic Policies: Springer Science & Business Media; 2006. 16 Cook DA, Levinson AJ, Garside S, Dupras DM, Erwin PJ, Montori VM. Instructional design variations in internet-based learning for health professions education: a systematic review and meta-analysis. Acad Med 2010; 85(5): 909-22. 17 De Vries T, Henning R, Hogerzeil H, Fresle D. Guide to good prescribing. Geneva: World Health Organization, 1994. 18 Maxwell SR. How should teaching of undergraduates in clinical pharmacology and therapeutics be delivered and assessed? Br J Clin Pharmacol 2012; 73(6): 893-9. 19 Brinkman DJ, Tichelaar J, Van Agtmael MA, De Vries TP, Richir MC. Self-reported confidence in prescribing skills correlates poorly with assessed competence in fourth-year medical students. J Clin Pharmacol 2015; 55(7): 825-30. 20 Richir MC, Tichelaar J, Stanm F et al. A context-learning pharmacotherapy program for preclinical medical students leads to more rational drug prescribing during their clinical clerkship in internal medicine. Clin Pharmacol Ther 2008; 84(4): 513-6.
89 In theory, there is no difference between theory and practice. But in practice, there is - Jan L. A. van de Snepscheut CHAPTER 6 E-learning on antibiotic prescribing – the role of autonomous motivation in participation: a prospective cohort study 6
Martine G. Caris Jonne J. Sikkens Rashmi A. Kusurkar Michiel A. van Agtmael
Journal of Antimicrobial Chemotherapy, August 2018 92 Chapter 6 h sbet cud nac atnmu mtvto ad hs piie e-learningefficiency. optimize thus and motivation of autonomous enhance importance could the subject, on the explain to e-learning education, face-to-face Preceding with participation. prescribing antibiotic improve could motivation autonomous increase to Interventions motivation. autonomous more with residents in higher is CONCLUSIONS with CI 1.5–4.6). associated positively was 95% 2.6, OR (adjusted hospital RAM academic an in residency for adjusted participation, motivation). autonomous more (i.e. RAM positive with residents in 62% and motivation) controlled more (i.e. RAM negative with residents in 41% was Participation (n=50). 58% was participation e-learning RESULTS regression. then analysed associations between RAM and participation in e-learning with logistic We of motivation. controlled amount of amount the the with estimates compared motivation that autonomous index an (RAM), motivation calculate to autonomous SRQ-a relative the used We access. e-learning received (SRQ-a)] Academic – the perceived importance of antibiotics and motivation [Self-Regulation Questionnaire knowledge, antibiotic on questionnaires out filled who Residents hospitals. teaching METHODS participation ine-learningonantibioticprescribing. We participation. e-learning in role their in motivation autonomous residents’ of role a the investigate to thereforeaimed play also could and education medical in achievements higher with associated is motivation Autonomous needed. therefore is participation affect that factors into Insight low. often are rates participation but OBJECTIVES ABSTRACT Eighty-six residents participated (74% female, mean age 30 years). Overall e efre a utcnr chr suy n w aaei ad two and academic two in study cohort multicentre a performed We E-learning is increasingly used in education on antimicrobial stewardship, Participation in non-obligatory e-learning on antibiotic prescribing antibiotic on e-learning non-obligatory in Participation INTRODUCTION
A common scenario in the clinical setting is that residents report a lack of knowledge on antibiotics and ask for more education on antibiotic prescribing. Yet when we offer them e-learning on the subject, participation rates are low. Why do they not participate, when they say they want to learn?
This question is important, as e-learning is increasingly used in antimicrobial stewardship programs.1,2 The advantages of e-learning are legion: it provides flexibility and allows interactivity and progress tracking, and, after initial development, modules are easily distributed among large groups and across the globe, against relatively small investments of time and costs. 3,4 At the same time, e-learning requires a lot of motivation, as it is usually non-obligatory and followed individually.
In contrast to earlier beliefs, as stated by the Self-determination Theory, motivation should not be viewed as a trait that is either present or absent, but rather as a 6 continuum with different states. More extrinsically motivated states, in which motivation comes from rewards (such as credits) are collectively called controlled motivation. Autonomous motivation comprises the more intrinsically motivated states, meaning that motivation originates from an interest in the subject or an understanding of its importance.5 Studies have shown that autonomous motivation is associated with higher study effort in medical students, 6 higher achievements in residents7 and more participation in continuing education among pharmacists. 8 Autonomous motivation could therefore also play a role in e-learning participation.
We investigated this for the important subject of antibiotic prescribing. Inappropriate use of antibiotics can be found in up to a staggering 50% of prescriptions, 9,10 which can lead to unnecessary side effects, costs and development of antimicrobial resistance. Education is viewed as an essential element of any hospital program that aims to influence antibiotic prescribing behavior.11 This is recognized by residents, who have expressed the need for more education on the subject. 12,13 We therefore developed an e-learning module on antibiotic prescribing and performed a multicentre cohort study among residents to investigate the association between autonomous motivation and participation in e-learning.
93 94 Chapter 6 a predominantly autonomous motivation profile, and a negative RAM indicates a predominantly controlled motivationprofile. RAM indicates anegative suggests and RAM profile, positive motivation a autonomous which predominantly a in +48, to -48 from score a generates This (−2). regulation andexternal (−1) regulation introjected (+1), regulation identified (+2), autonomous regulationintrinsic of subscales four the of scores adding and weights, assigning of by amount the calculated is RAM motivation. controlled estimating of amount the with compared motivation by score self-determination general a provides that index an (RAM), Motivation Autonomous Relative measure to used is activity using four subscales and was previously assessed for internal consistency. SRQ-a the of version Dutch The researcher andthree infectious diseasesphysicians. expert. The new version was assessed for content validity once more, by one physician diseases physicians, a medical microbiologist, a general practitioner and an assessmentinfectious by validity content for assessed been had which test, designed previously a from slightly adapted was test This questions. 37 comprised test knowledge The received areminder, extending thecredentials foranotherweek. e-learning module, which were valid for two weeks. After two weeks, non-responders the for credentials login received questionnaire the completed who respondents All (http://selfdeterminationtheory.org/self-regulation-questionnaires/). only purposes research for used be will it that declaration a providing after and registration after website, SDT the from downloadable is SRQ-a the of version English The (SRQ-a). aquestionnaire of antibiotics, and the Dutch out version of the Self-Regulation Questionnaire – Academic filled and consisting of a knowledge test on information antibiotics, questions on the perceived importance background provided Participants Data-collection mandatory educationonantibioticprescribing. in-hospital antibiotic prescriptions. At the time of study, none of the departments had ofnumber high their of because geriatrics, clinical and cardiology medicine, internal during a scheduled teaching session. The participatestudy was conducted in the to departments of hospitals teaching two and care) tertiary (providing centres medical university two from residents asked and study cohort multicentre a conducted We Design MATERIAL ANDMETHODS 14
assesses motivation for a specific educational specific a for motivation assesses 15 It It We developed an e-learning module through P-scribe, a web-based programme based on the WHO Guide to Good Prescribing, which tracks participation. 16 The module comprised a case of endocarditis, interspersed with information on antibiotics. The subject was chosen because a more complicated infection, such as endocarditis, allowed us more room for background information. Participants were not aware of the subject before participation. The e-learning module included questions with direct feedback to increase interactivity. Local and national guidelines were provided to assist in decision making and to mimic the process of prescribing in the clinical setting. Completion took 60-90 minutes; participants were allowed to stop and resume. One physician-researcher and three infectious diseases physicians independently assessed the module for content validity.
After completion of the module, we administered the Instructional Materials Motivation Survey (IMMS). The IMMS is a frequently used questionnaire that measures motivation for educational materials, and has been tested extensively for validity in medical education.17,18 The IMMS consists of 36 statements on four domains (ARCS) 19: 6 The Attention domain assesses whether the material can hold the student‘s attention; Relevance assesses whether the content relates to future application; Confidence assesses the connection with prior knowledge; and Satisfaction assesses appreciation of the material. We used the IMMS scores to assess the value of our e-learning as an educational tool.
Analysis Descriptive analyses were used to summarize study population characteristics and IMMS scores. We calculated means with standard deviations for normally distributed data, and medians with IQRs for data with non-normal distribution.
To our knowledge, there is no literature on the psychometric properties of the SRQ-a regarding responsiveness (i.e. whether the questionnaire is capable of measuring changes in score). As the scale of RAM spans from -48 to +48, we considered a 10 point difference relevant, indicating a change in RAM of around 10%. We therefore divided RAM by 10 and then assessed the association between RAM and e-learning participation with logistic regression analysis, adjusting for residency in an academic hospital, gender, clinical experience and prior knowledge on antibiotic prescribing (measured as test score). All analyses were performed in SPSS 22.0 for Windows (IBM SPSS Inc., Chicago, IL, USA).
95 96 Chapter 6 association betweenreceiving areminder andparticipation. and there were no differences between female or male participants, nor was there model,an either in confounders significant not were knowledge prior and experience clinical More modifier. effect an not was but 1.5-4.6), CI (95% 2.6 of OR byadjusted increase an participation providing confounder, significant of a was hospital odds academic an the in Residency RAM, 2.1. in increase 10-point means every This for 1.3-3.4). CI that (95% 2.1 of OR RAM and crude a with between e-learning, in association participation significant a showed analysis regression Logistic the RAMpercentile groups. in participation mean the shows 1 Figure motivation). autonomous more (i.e. RAM with negative RAM (i.e. Overallmore controlled motivation) 1). residents and in 41% 62% was table in Participation (n=50). residents 58% with in was positivee-learning the in (characteristics participation study the in participated residents Eighty-six RAM andparticipation RESULTS TABLE 1 RAM Residency, n(%) Academic hospital, n(%) Clinical experience (years), n(%) Female, n(%) Age (years), mean(SD) Characteristics Study populationcharacteristics internal medicine clinical geriatricsclinical median (IQR) cardiology min–max other 1-4 >4 ≤1 -22 to +37 7.3 (2-18) 63 (73) 14 (16) 58 (67) 22 (26) 40 (47) 24 (28) 64 (74) 30 (5) 4 (5) 5 (6) Almost all residents (97%) agreed or strongly agreed that strong knowledge of antibiotics is important in their career and that they would like more education on the appropriate use of antibiotics and on antibiotic resistance.
IMMS More than half of the participants completed the e-learning module (n=28, 56%), of which 23 completed the IMMS. The median overall IMMS score was 71% (IQR 66%- 78%). Median scores on the separate domains of Attention, Relevance, Confidence and Satisfaction were 70% (IQR 65%-82%), 76% (IQR 69%-82%), 76% (IQR 62%- 78%), and 63% (IQR 57%-73%), respectively.
6
FIGURE 1 Mean participation in e-learning in RAM percentile groups
DISCUSSION
Our study shows that residents who report more autonomous motivation for education on antibiotics are more likely to engage in an e-learning module on the subject. These findings are in line with earlier studies on type of motivation and performance in medical education: autonomous motivation was associated with higher study effort in medical students6 and more participation in continuing education among 97 98 Chapter 6 increases, indicating that attitude towards a subject influences motivation to learn. education for motivation autonomous with their subject, the identify of importance or students value the if motivation: autonomous to relation in shown been also behaviour. influence can in education change that a suggesting to thereby leads behaviour, turn in which attitude, in change a to leads understanding better that states instance, for model, KAB behaviour.The change to aiming when attitudeof importance the on focus which (KAB)model, Attitude,change Behaviour (TPB) behaviour planned of theory the as such models change activities. learning in engage thus and subject the on more learn to reasons with identify can they that so rationale, of meaningful a sense with learners a providing by lack enhanced be can can Relatedness relatedness. it method, learning remote a as However, learning. of form appeals to autonomy already and competence, E-learning as it e-learning? provides learners in with a participation flexible, adaptive improve to us help this can how So motivation byincorporating theseprerequisites inoureducationalactivities. community). learning professional a competence efforts), learning in to belonging of sense (a choice relatedness and material) the mastering of capable (feeling a having of perception (the autonomy a be not thus desirable would solution. The SDT effective, points to several perhaps prerequisites for autonomous although motivation: obligatory, e-learning Making and learning deep facilitates taught is what of integration motivation autonomous motivation, controlled importance). to or value in subject’s interest the with genuine identifying a or from subject, the (coming autonomous or rewards) or sanctions from (originating controlled as motivation describes (SDT) theory self-determination The stone, butcanvaryacross different subjects, in set not is motivation of state person’s importantly,a More states. different with continuum a along dynamic as rather but absent, or present either is that trait a as viewed be not should motivation beliefs, earlier to However,contrast motivation. in subject, the on available data of amount small theprovided,with is line this in when is participation moreof for lack but education use. Still, participation in the e-learning was only 58%. This discrepancy, i.e. the wish is antibiotics of knowledge important in their career, strong and that they would like more education on that its appropriate indicated residents of 97% study, our In on antibioticprescribing hasnotbeenpreviously described. pharmacists. 8 However, the role of autonomous motivation in e-learning participation 23 and is therefore the sought after state of motivation.of state after sought thereforethe is and 26 This approach is supported by several behaviourseveral by supported is approach This 24 This means that we can enhance autonomous enhance can we that means This 21 andcanchangeovertime. 20 and is often attributed to a lack of lack a to attributed often is and 27 and the Knowledge,the and 5,22 n contrast In 28 hs has This 21,25
5,22
For e-learning in antimicrobial stewardship, this means that face-to-face education prior to the module, explaining the importance and thereby influencing attitude, could enhance autonomous motivation and thus increase participation. 29,30 This is already applied in “blended” learning, which is increasingly used as an innovative and effective method to integrate e-learning with face-to-face instruction. 31
Our study has strengths and limitations. To our knowledge, this is the first study to address the role of autonomous motivation in participation in e-learning on antibiotic prescribing. Although our sample was limited, we included residents from multiple centres and specialties, and found a consistent association between autonomous motivation and participation across subgroups. We adjusted for factors that could have influenced participation such as workload (which is usually considered lower in University Medical Centres compared with teaching hospitals), clinical experience, and previous knowledge on the subject of antibiotics. Our findings are supported by the SDT, which is a rigorously investigated and validated theory on motivation, and fit into the larger frameworks of behaviour change. However, supervisors of the 6 participating residents were aware of the study and availability of the e-learning. This may have triggered participation in residents with more controlled motivation, which could have reduced differences in participation with their autonomously motivated colleagues. The module was available for three weeks; participation rates could have been higher had availability been extended. We did not collect data on reasons for non-participation; factors unrelated to autonomous motivation, such as distractions at work or at home, could have influenced the effect.
E-learning is increasingly used in antimicrobial stewardship interventions, but simply making a module available may not be sufficient, as many people may not participate.26 Participation could be improved by increasing autonomous motivation, for instance by combining e-learning with face-to-face education that explains the importance and relevance of prudent use of antibiotics. Future studies should focus on ways to provide these learning environments, and investigate the effect of enhanced autonomous motivation on participation.
Parts of the results were presented previously at the Conference of the Nederlandse Vereniging voor Medisch Onderwijs (NVMO), Rotterdam, November 12 th 2015 (abstract A12.2) and the Conference of the Association for Medical Education in Europe (AMEE), Barcelona, August 29 th 2016 (abstract #3N3 133375).
99 100 Chapter 6 6 5 4 3 2 1 REFERENCES 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 equation modellinganalysis. Health. solutionshelp? can online-learning 10 Lancet Dis Infect 17 224-40. autonomous motivation: The moderating role ofdifferentiated instruction. 10 of apan-European survey. Florida, learning USA:Florida 2003. and self-directed State University; Keller’s to materialscourse. aweb-based motivation instructional survey Toxicol application programme Pscribe inproblembased pharmacotherapy teaching. ofmotivationThe matters. quality two domains. antimicrobial prescribing experiences. Dis BMC Infect care theAntibiotic juniordoctors: Prescribing insecondary practice (APED). Education amongDoctors 4 antimicrobial stewardship. Healthcare guidelinesfor EpidemiologyofAmerica developing aninstitutionalprogram to enhance hospital. Development: AFocus onMotivation Among Pharmacists. motivation ofresidents. Kusurkar RA, RA, Kusurkar Ten Cate TJ, Vos CM ofHuman Motivation, Development, and AMacrotheory RM.Self-Determination EL,Ryan Deci Theory: Rocha-Pereira N, Nathwani N, Lafferty D. Educating healthcare professionals in antimicrobial stewardship: Gordon M,Chandratilake M,BakerP. Lowe-learning. amodel fidelity,for highquality: E,Robilotti HolubarM,Nahrgang S Nathwani D, Guise T, for globalantimicrobial stewardship. M.e-learning Gilchrist Guay F, Roy A, Valois P. Teacher asapredictor structure ofstudents’ perceived competence and Chanal J, Guay F. Are Autonomous andControlled Motivations School-Subjects-Specific? Furriel FT, LagunaMP, Figueiredo AJ Design. Keller JM.Development ofInstructional andUse Model oftheARCS DM. Gabrielle The effectsof technology-mediated strategies instructional onmotivation, performance, Cook DA, Beckman TJ, Thomas KG A. Doorn The value content ofalearning management system (LCMS) for assessment ofaninternet Vansteenkiste M,Sierens B E, Soenens RM,ConnellRyan JP. Perceived andinternalization: locusofcausality examining reasons forin acting C.Awindow KellyN,Rees into thelives narrative K, Mattick exploring ofjuniordoctors: interviews M,Moore E Gharbi LS,Castro-Sanchez Pulcini C,Gyssens IC.How to educate prescribers inantimicrobial stewardship practices. Dellit Mcgowan RC, JE,TH, Owens Jr. Pulcini C,Cua E, LieutierF Tjin ATSL, A,Croiset Boer De G Baldwin CD, JP ShoneL,Harris : 192-202. : 258-63. : 579. : e0134660. 2007; Can Psychol Eur Dis JClinMicrobiol Infect 101 2016; J Pers Psychol Soc 2017; : 51-102. 2008; 16 17 : 456. Pediatrics : 257-8. 49 BJU Int etal Clin Infect Dis Clin Infect : 182-5. Adv Health Sci Educ Theory PractAdv Educ Theory HealthSci etal 1989; . Antibiotic misuse:aprospective clinicalauditinaFrench university 2013; etal 2011; J Educ Psychol etal . Development ofanovel to enhance curriculum theautonomy and etal etal etal J Antimicrob Chemother J Antimicrob 2007; 57 et al etal J Antimicrob Chemother J Antimicrob . Factors in Influencing Continuing Participation Professional 112 . . Educating front-line cliniciansaboutantimicrobial resistance. 2007; 128 : 749-61. . Training ofEuropean urology residents results inlaparoscopy: etal . Measuring motivational of courses: characteristics . Measuring applying How a structural motivation affects academic performance: . . 26 Motivational profiles perspective: from aself-determination Infectious Diseases Society of America and the Society for andtheSociety ofAmerica DiseasesSociety Infectious : 1223-8. : 633-6. . Aneedsassessment studyfor optimisingprescribing : 277-80. 44 2009; : 159-77. 101 : 671-88. J Contin Educ Health Prof 2015; 2013; 2014; 70 18 : 3175-7. 69 : 57-69. : 2274-83. Acad Med J InstrDev Br JEduc Psychol Lancet Dis Infect Basic ClinPharmacol 2009; 2016; 1987; Clin Teach PLoS One Virulence 84 36 : 1505-9. : 144-50. 10 2017; : 2-10. 2013; 2017; 2013; 2015; 87 : 23 Williams GC, Wiener MW, Markakis KM et al. Medical students’ motivation for internal medicine. J Gen Intern Med 1994; 9: 327-33. 24 Deci EL, Ryan RM. The “What” and “Why” of Goal Pursuits: Human Needs and the Self-Determination of Behavior. Psychol Inq 2000; 11: 227-68. 25 Kusurkar RA, Croiset G. Autonomy support for autonomous motivation in medical education. Med Educ Online 2015; 20: 27951. 26 Orsini C, Binnie V, Wilson S et al. Learning climate and feedback as predictors of dental students’ self- determined motivation: The mediating role of basic psychological needs satisfaction. Eur J Dent Educ 2017: [Epub ahead of print]. 27 Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process 1991; 50: 179-211. 28 Schneider B, Cheslock N. Measuring results: gaining insight on behavior change strategies and evaluation methods for environmental education, museum, health, and social marketing programs. San Francisco, CA: CoEvolution Institute, 2003. 29 Kusurkar RA, Croiset G, Ten Cate TJ. Twelve tips to stimulate intrinsic motivation in students through autonomy-supportive classroom teaching derived from self-determination theory. Med Teach 2011; 33: 978-82. 30 Kusurkar R, Ten Cate O. AM last page: Education is not filling a bucket, but lighting a fire: self- determination theory and motivation in medical students. Acad Med 2013; 88: 904. 31 Liu Q, Peng W, Zhang F et al. The Effectiveness of Blended Learning in Health Professions: Systematic Review and Meta-Analysis. J Med Internet Res 2016; 18: e2. 6
101 If you want to encourage someone to do something, make it easy - Richard H. Thaler CHAPTER 7 Important aspects of effective e-learning: the right timing and appropriate behavioural interventions to educate junior doctors on antibiotic prescribing 7 and infection control
Martine G. Caris Michiel A. van Agtmael Christina M.J.E. Vandenbroucke-Grauls
Submitted for publication A summary of the article (in Dutch) was previously published in the 2 nd edition of ‘Praktijkgids Antimicrobial Stewardship in Nederland’ initiated by the Dutch Working Party on Antibiotic Policy (SWAB), 2018. 104 Chapter 7 uue tde sol fcs n nraig pae hog isiuinl upr and investigate theeffectofbehavioural interventionsine-learningondailypractice. support institutional through uptake increasing on focus should studies residency.Future months 3-4 after be to appears e-learning introductory for time best the doctors, these For acceptable. control infection and prescribing antibiotic on module NEXT STEPS not participating. participated. Residents most frequently reported lack of (scheduled) time as cause for (25%) 15 module, the for credentials login received surgery) 22 medicine, internal (38 residents Sixty interventions. behavioural acceptable commitment” “public and They considered “nudging”, “creating a social standard”, “implementation intention” 2-6). range months, 3-4 (average residency of months first their during information OUTCOMES and uptakeamongresidents ofinternalmedicineandgeneral surgery (years1-4). valueits assessed and interventions, incorporatedthese which module e-learning an investigate the acceptability of several and behavioural e-learning, interventions. such They then offer developedto time optimal the determine subjects, these on needs educational their assess to specialties, different of residents with control infection APPROACH junior doctorsfindsuchinterventionsacceptableisyettobeexplored. whether but practice, clinical in uptake e-learning enhance could nudging, as such at what time during residency this would be most effective. Behavioural interventions, control by junior doctors. Introductory e-learning could prove useful, but it is unkown PROBLEM ABSTRACT There is an urgent need to improve antibiotic prescribing and infection and prescribing antibiotic improve to need urgent an is There The authors conducted in-depth interviews on antibiotic prescribing and l nn itriwe rpre te hd o be rcpie o new to receptive been not had they reported interviewees nine All Junior doctors find behavioural interventions incorporated in an e-learning PROBLEM
Junior doctors often report a lack of knowledge and skills, specifically concerning infection control and antibiotic prescribing. 1 This is reflected in frequent deviation from infection control guidelines and in the number of unjustified prescriptions: misuse of antibiotics occurs in up to 50%. 2,3 In many hospitals, junior doctors are responsible for the majority of antibiotic prescriptions, and play a key role in infection control, due to their frequent interactions with patients. Education aimed at guideline adherence in busy daily practice is therefore much needed.
E-learning appears to be a valuable method, as it has shown to improve prescribing skills, has low costs, is easily distributed among large groups, and can easily be adapted to changes in guidelines.4 However, an important factor in the uptake of education is the learner’s ability to absorb information. The transition from student to physician is often reported as very stressful, which could render junior doctors less receptive to education at the commencement of clinical work. 5 To achieve adequate uptake, determining the most opportune moment to offer such an e-learning is paramount. 7 Although education is a prerequisite, it is increasingly recognized that improving guideline adherence in daily practice requires behaviour change. Measures to support the effect of e-learning are therefore essential. Several concepts from the behavioural sciences, not yet commonly applied in healthcare, could aid in achieving this. Firstly, an environment with committed role models is an important factor in sustainable practice.3 Creating a social standard, for example by having supervisors advocate prudent use of antibiotics, or by incorporating them as role models in an e-learning module, could enhance chances of behaviour change. In addition, formulating a commitment (also known as an implementation intention 6), such as signing a hospital-wide petition to reduce healthcare-associated infections, has been shown to increase chances of putting new knowledge into practice. A third promising approach is nudging, a friendly push to encourage desired behaviour. It has been shown that nudges displayed as posters in general practitioners’ offices can reduce unnecessary antibiotic prescriptions and, when displayed next to dispensers can increase the use of hand desinfectant.7,8
Although these interventions have been shown to affect behaviour in daily practice, to our knowledge, their use in e-learning has not been described before. Incorporating behavioural interventions such as these in an e-learning module may help further improve junior doctors’ antibiotic prescribing and their adherence to infection control guidelines. However, it is not known whether such interventions are acceptable to 105 106 Chapter 7 consistency were alsotakenintoconsideration. browsers). multiple in module the testing buttons, and links all checking (e.g. usability incorporationand copyright, quizzes), of (e.g. engagement content as such dimensions, seven on questions module The 1). include which questions’, screening design ‘e-learning the applying (table by assessed was design course a into translated and expert educational an physicians. After defining the key concepts, learning objectives were formulated with experts, teaching behavioural from scientists, and input experienced with medical microbiologists defined and were infectious diseases goals learning Firstly, interviews. the in reported frequently most barriers the addressed which control, infection and We developed an e-learning module aimed at practical skills for antibiotic prescribing E-learning and participationofatleastoneresident from allmajorspecialties. antibiotics and adequate infection control. Interviews continued until ofdata saturation use prudent to commitment a sign and intention implementation an formulate to willing be would they whether and subjects, these on e-learning introductory an for time best the guidelines), control infection to adherence and prescribing good to barriers (i.e. residency their of start the at experienced had residents difficulties assess to were objectives Main control. infection and stewardship”), “antibiotic as specialties. Topics were antibiotic prescribing, prudent use of antibiotics (also known In 2016, we conducted in-depth, semi structured interviews with residents of different Interviews APPROACH users. end- the among implementation assess to finally, and acceptable, are module the inincorporated interventions behavioural whether assess to module, a such offer to momentopportune most fromthe input determine with to module doctors, a junior junior on based module, doctors’ needs, e-learning which an incorporates behavioural of interventions. Our development goal was the to develop describes paper This the to target audience, or appeal worse, are not perceived as do annoying, they can measures be counterproductive. these if because important, is This doctors. junior 9 ae f aiain vsa dsg, eraiiy and learnability, design, visual navigation, of Ease 10 The behavioural interventions were incorporated in the e-learning module, starting by creating a social standard. In our hospital, we had recently founded a group of “antibiotic champions”: medical specialists who agreed to propagate prudent use of antibiotics to their specialty’s peers,1 and to function as spokespersons for antibiotic stewardship. One of the assignments in the module entailed an overview with pictures of all the antibiotic champions; participants were asked to point out “their” champion. After completion of most of the module, participants were asked to formulate their own implementation intention, specifying when, where, and how they would put their newly gained knowledge into practice. Finally, they were asked to “sign” a commitment to prudent use of antibiotics and adequate infection control, by clicking a button (figure 1). This generated a personalized course certificate (constituting a nudge) stating that they had successfully completed the course and had joined the network of doctors who commit themselves to prudent use of antibiotics and adequate infection control.
Evaluation In 2017, we conducted a study among residents in years 1 through 4 of their residency within the departments of internal medicine and general surgery, to assess the value 7 and uptake of the e-learning module, including reasons for (not) participating, through short surveys.
FIGURE 1 Public commitment. Text reads “Prudent use of antibiotics and adequate infection control are indispensable in patient care. Together, we aim to provide the very best for our patients; today and in the future! Join the hospital physicians that see to this every single day, by pushing the blue button.” Button reads:Figure “YES, I’m1 – joiningPublic this commitment. network.” Text reads "Prudent use of antibiotics and adequate infection 107 control are indispensable in patient care. Together, we aim to provide the very best for our
patients; today and in the future! Side with the hospital physicians that see to this every single
day. Push the blue button join us." Button reads: "YES, I’m joining this network." 108 Chapter 7 had thetimetodoso. The remaining 9 residents indicated that they had planned to participate but had not a reported whom current of focus on research without clinical duties as their reason for 5 not participating. responded, 14 residents, non-participating 45 the of Out module in an the educational session on the incorporate subject, with live discussion to of clinical cases. made were suggestions Additional cases. clinical more include residents notfinishingthemodule.Some residents indicatedthatthemoduleshould when it has to be completed alongside daily clinical activities. This led to many of the priority have not does e-learning that indicated However,also interviews. they prior the in peers their by expressed as control infection and antibiotics on education for need the confirmed residents these general, In feedback. with us provided whom of months. three their reasons for for not partaking. Fifteen residents valid (25%) participated in the credentials, module, ten for residents non-participating and login feedback, for asked were residents Participating personal received months) three of A total of 60 residents (38 internal medicine, 22 surgery, all employed for a minimum E-learning or signingapubliccommitment. intentionimplementation an problemformulating no have would they reportedthat interviewees All adherence. guideline aid would call of port first their knowing and example by Leading important. very considered was departments respective their in incorporate clinical cases. Regarding the use of role models, creating a social standard be aimed at clinical practice, address logistics and valuable sources of information, and antibiotic prescribing and infection control very useful and felt such a module should were able to process new information. Residents considered an e-learning module on smoke “the or settles” clears”, mostly dust around 3-4 “the months of experience when (range 2-6 moment months), after a which they to referred all They residency. doctors experienced an overflow of information during the hectic first period of their junior all orbut common, experience, was topics specialty, various on of education introductory regardless background: residents, all from story consistent There a months). was 6-48 (range months 20 was experience clinical of level mean female, the were Four participated. Otorhinolaryngology and Neurology, Paediatrics, surgery,surgery,General Orthopaedic medicine, Internal in residents nine of total A Interviews OUTCOMES NEXT STEPS
With this study, we found that when offering e-learning, it is important to determine the most opportune moment. Regardless of specialty, residents experience a hectic first few months during which they are not receptive to new information. This should be taken into account when modules are introduced. In addition, our study confirms that junior doctors have a need for education on antibiotic prescribing and infection control.1 We found that they mainly request practical information, such as phone numbers within the institution and easy-to-find links to guidelines, combined with clinical cases. This indicates that it is useful to develop a tailored module or to adapt existing modules to local circumstances.
The ultimate goal of educational interventions is to influence behaviour in daily practice. Although only scarcely applied in healthcare, behavioural interventions could be useful to support education and increase uptake. As interventions to improve antibiotic prescribing and adherence to infection control guidelines are often met with resistance, it is important to know whether these interventions are acceptable before widely introducing them. We found that “nudging”, “creating a social 7 standard”, formulating an “implementation intention” and “public commitment” are easily incorporated in a module and are all acceptable to junior doctors, which is a first step in determining their value in e-learning.
The most obvious limitations of our study are that we did not assess the effect on prescribing skills and infection control in clinical practice, and the small sample size. In addition, our study suffers from suboptimal participation, a common downfall in non-obligatory e-learning. This is reflected in the implementation phase of our study, which shows that scheduled time to participate in the module is essential.
There is an urgent need to improve antibiotic prescribing and infection control among junior doctors and e-learning could be a valuable tool to do so. Our study shows that to fully benefit from e-learning, it is important to involve junior doctors in the development process. During the first few months of their residency, they are not receptive to learning new skills, which should affect decisions on the timing of introductory e-learning. The behavioural interventions of creating a social standard, formulating an implementation intention, signing a commitment, and receiving a certificate as nudges are all acceptable to junior doctors. We believe that this topic merits further exploration, as these interventions are easily incorporated in e-learning modules and could potentially enhance uptake. Moreover, this does not only applies to antibiotic prescribing and infection control, but to all educational subjects requiring 109 110 Chapter 7 study. The authors wish to thank Inge Soons, MSc for conducting the evaluation of the pilot ACKNOWLEDGEMENTS is vital. modules, the in partake to time scheduled into translated commitment, institutional behaviour change. Our study shows that for learners to fully benefit from e-learning, REFERENCES
1 Gharbi M, Moore LS, Castro-Sanchez E et al. A needs assessment study for optimising prescribing practice in secondary care junior doctors: the Antibiotic Prescribing Education among Doctors (APED). BMC Infect Dis 2016; 16: 456. 2 Davey P, Marwick CA, Scott CL et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017; 2: CD003543. 3 Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004; 141: 1-8. 4 Maxwell S, Mucklow J. e-Learning initiatives to support prescribing. Br J Clin Pharmacol 2012; 74: 621-31. 5 Teunissen PW, Westerman M. Junior doctors caught in the clash: the transition from learning to working explored. Med Educ 2011; 45: 968-70. 6 De Vet E, Oenema A, Sheeran P, Brug J. Should implementation intentions interventions be implemented in obesity prevention: the impact of if-then plans on daily physical activity in Dutch adults. The International Journal of Behavioural Nutrition and Physical Activity 2009; 6: 11-. 7 Meeker D, Knight TK, Friedberg MW et al. Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA Intern Med 2014; 174: 425-31. 8 Caris MG, Labuschagne HA, Dekker M, Kramer MHH, Van Agtmael MA, Vandenbroucke-Grauls C. Nudging to improve hand hygiene. J Hosp Infect 2017. 9 Lewis KO, Cidon MJ, Seto TL, Chen H, Mahan JD. Leveraging e-learning in medical education. Curr Probl Pediatr Adolesc Health Care 2014; 44: 150-63. 10 Asarbakhsh M, Sandars J. E-learning: the essential usability perspective. Clin Teach 2013; 10: 47-50. 7
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ANTIBIOTIC STEWARDSHIP AND INFECTION CONTROL IN GUIDELINES To change something, build a new model that makes the existing model obsolete - R. Buckminster Fuller CHAPTER 8 Adapting empiric antibiotic treatment for suspected bloodstream infection to increasing Gram-negative resistance
Martine G. Caris Vincent M.T. de Jong Jonne J. Sikkens 8 Johannes Berkhof Jan Veenstra Marc L. van Ogtrop Christina M.J.E. Vandenbroucke-Grauls Michiel A. van Agtmael
Submitted for publication 116 Chapter 8 may induceovertreatment. pathogenssubgrouplikely resistancea therapyof on of empiric based adapting that of risk suggests study therapy.This empiric the of adaptation for threshold the accepted on generally than higher impact are subgroup little this in have rates resistance therefore when even pathogens undertreatment, of subgroup a of rates Resistance negative. remain often cultures blood and pathogens causative possible CONCLUSIONS 99% overtreatment (4094of4140patients). in resulting patients, all for treatment empiric extensive to led have would >10% of resistance to showed 3GC. In GNB this cohort, of adapting empiric 19% treatment (GNB). based on bacteria 3GC-resistance Gram-negative with with cultures) patients blood of positive 63% patients, all of (9% 374 cultures, blood positive had (14%) RESULTS lead toempiricovertreatment. a often how hypothetical adaptation of empiric calculated therapy based on Gram-negative resistance We would ‘extensive’). (considered 3GC+gentamicin, vancomycin+gentamicin carbapenem, or a B) or Netherlands) the in treatment BSI empiric ‘standard’ considered (3GC, cephalosporins second-/third-generation A) either with treatment intravenous empiric received and drawn cultures blood had who 2016, METHODS causative possible many with pathogens, suchassuspectedbloodstream infection (BSI). infections of overtreatment affects approach this how assess to aimed We 10%. reach pathogen likely most the of rates resistance BACKGROUND ABSTRACT We included 4140 patients, 3556 (86%) received empiric 3GC. 589 patients We studied patients admitted to 3 Dutch hospitals between 2010 and 2010 between hospitals Dutch 3 to admitted patients studied We Empiric antibiotic treatment guidelines are usually adjusted when adjusted usually are guidelines treatment antibiotic Empiric n ains upce o bodtem neto, hr ae many are there infection, bloodstream of suspected patients In INTRODUCTION
Bloodstream infections (BSI) are a major cause of infectious disease morbidity and mortality worldwide.1 In the Netherlands, empiric treatment, i.e. before susceptibility results are known and when a clear focus of infection is lacking, usually consists of third-generation cephalosporins (3GC), such as ceftriaxone. However, an increasing number of BSI are caused by bacteria that have developed 3GC-resistance. 2,3 Empiric therapy has therefore shifted to carbapenems or aminoglycoside combination therapy for patients at an increased risk of 3GC-resistant infection. 4 Unfortunately, these antibiotics are associated with important adverse events ( Clostridium difficile infection and acute kidney injury, respectively 5-8), and (over)use of antibiotics in general induces further development of antibiotic resistance. 9 In addition, current guidelines apply risk factors (such as prior colonization with 3GC-resistant pathogens) that have very low predictive values, which means we are unable to accurately identify these patients.10
The basis of empiric antibiotic treatment is the expected susceptibility of the most likely causative pathogen.11 Although not set in stone, 10-20% resistance is generally considered the threshold to adapt empiric drug regimens to the increased resistance rate. This makes sense for infections such as urinary tract infections (UTI); most are caused by the same bacterial species, thus increased resistance in that species will 8 affect most patients. Escherichia coli causes up to 90% of UTI. If 20% of the E. coli in urine cultures are resistant to amoxicillin-clavulanic acid, empirically treating a patient with amoxicillin-clavulanic acid would lead to an 18% chance of inappropriate initial therapy, which is not considered acceptable.
Gram-negative bacteria in general, E. coli in particular, are frequent causes of BSI, and in the Netherlands, E. coli’s 3GC-resistance is approaching the 10% threshold.2 This will soon lead to discussions on whether empiric treatment for suspected BSI should be adapted to carbapenems or aminoglycoside combination therapy for all patients. However, the question arises whether this is the best approach to determine empiric treatment for complex infections such as BSI. Firstly, as mentioned above, the threshold for adjustment applies to single pathogens,12 while there are many pathogens that can cause BSI. Secondly, there is a focus on culture-proven BSI, while in at least 80% of patients suspected of BSI, blood cultures remain negative. 13 This process thus disregards the larger part of patients physicians will encounter, which compromises the applicability of these empiric treatment guidelines in clinical practice. 14
117 118 Chapter 8 3GC-resistance was intrinsic or acquired, based on EUCAST wild type susceptibility type wild EUCAST on based acquired, or intrinsic was 3GC-resistance 3GC-susceptibility. If tested, ceftriaxone susceptibility was used. We assessed whether before. proposed as production, We reviewed 3GC-resistance regardless of extended-spectrum beta-lactamase (ESBL)- micro-organisms in the 90 days prior to infection, and/or hospital-acquired infection. cephalosporin-resistant of carriage known and/or infection, to prior days 30 the in fluoroquinolones and/or ofcephalosporins use as defined were infection resistant 3GC- for factors risk guidelines, Dutch Following thereafter. drawn when acquired hospital- and admission, of hours 48 within drawn were cultures blood if acquired to 24 hours after collection of blood cultures. Episodes were considered community- up before, hour 1 within started therapy antibiotic as defined was therapy Empiric Definitions (acute kidneyinjury, events adverse and mortality in-hospital BSI, 3GC-resistant for factors risk applied currently evaluated We excluded. were endocarditis or neutropenia malignancies, therapy.combination haematologicvancomycin/gentamicin active and Patientswith therapy,combination 3GC/gentamicin carbapenem, second-/third-a 3GC), (hereafter: cefuroxime and a ceftriaxone i.e. guidelines: activity, anti-pseudomonal (hospital) without cephalosporin Dutch generation to according regimens antibiotic included once, regardless of blood culture results (positive or negative). We included were patients All prescribed. were antibiotics intravenous broad-spectrum empiric and obtained were cultures blood whom from 2016, and 2010 between admitted years),18 (≥ patients adult cultureresults?’Wethereforeall awaiting included while start I should antibiotic Which lacking. is focus clear a but be infection, could bloodstream it fever, a has patient ‘My training): (in teaching physicians for practice two clinical in and tertiary scenario common a one mimic to aimed We in Netherlands. The Amsterdam, study in hospitals cohort retrospective a conducted We METHODS adverse events. and mortality therapy, empiric between associations and events, adverse of occurrence the assessed additionally We rates. overtreatment and under- impact would therapy empiric of adaptation to approaches different two how calculating the impact of Gram-negative resistance on a cohort of patients suspected of BSI, and be applied to complex infections such as bloodstream infection (BSI), by investigating We aimed to assess whether the current approach to adaptation of guidelines should Clostridium difficile 13 Cefotaxime susceptibility was used as proxy for proxy as used was susceptibility Cefotaxime infection). 4 patterns.15 Bacterial species for which cefotaxime nor ceftriaxone sensitivity was tested, were judged intrinsically resistant or intrinsically sensitive, based on EUCAST patterns.
For potential skin contaminants (Corynebacterium species, Bacillus species, Propionibacterium species, coagulase-negative staphylococci, viridans group streptococci, Aerococcus species, Micrococcus species) bacteraemia was determined by growth of the same genus in two or more blood cultures drawn on separate occasions,16 otherwise the episode was considered culture-negative. Antibiotic therapy was assessed following Dutch guidelines and judged overtreatment (if too broad spectrum), appropriate, or undertreatment (if too narrow spectrum). Empiric therapy was considered overtreatment if antibiotics were anything other than 3GC- monotherapy and A) blood culture later showed a 3GC-susceptible microorganism or B) blood cultures were negative, and the patient had no risk factors. In case of a documented type I beta lactam allergy, carbapenem or vancomycin/gentamicin combination therapy was considered appropriate. Empiric undertreatment was defined as 3GC-monotherapy and A) blood culture later showed a micro-organism with in vitro 3GC-resistance or intermediate susceptibility or B) blood cultures were negative but the patient had at least one risk factor. Adverse events included acute kidney injury (i.e. increase of ≥ 1 in RIFLE criteria 17) and Clostridium difficile infection (positive C. difficile toxin A and/or B in faeces, positive C. difficile culture 8 or positive PCR on C. difficile toxin16). Comorbidities were assessed by ICD-codes where available, otherwise activity-based costing information was used. Charlson Comorbidity Index (CCI) scores were calculated and categorized as originally denoted, age was disregarded to prevent double adjustment. 18
Analysis Descriptive statistics were applied as appropriate. We used contingency tables in Excel (Microsoft Office Excel 2010) to calculate the impact of two different approaches to adaptation of empiric therapy on the rates of under- and overtreatment, as well as numbers needed to treat. To model the effect of further increasing prevalence of 3GC-resistance, we created formulas to express the value of each cell in terms of 3GC-resistance (r). In contrast to positive and negative predictive values, likelihood ratios are not influenced by the prevalence of disease. 19,20 We therefore based the formulas of each cell on the positive likelihood ratio divided by the negative likelihood ratio (for formulas see Supplementary Table 1). We then modelled the increase of 3GC-resistance in Gram-negative bacteria with a step-size of 1%, from the current prevalence to 100%, to evaluate the effect of these approaches with further increasing 3GC-resistance. The proportion of patients with and without risk factors 119 120 Chapter 8 overtreatment and mortality, andatrend towards ICU-admission. hospital mortality at any time interval regression(table 2), but did show an association between Logistic (n=343). in- or ICU-admission, episodes and undertreatment empiric between of association no showed 8% in occurred guidelines) current by proposed factors risk of presence or results susceptibility on (based Undertreatment (n=248). prescriptions aminoglycoside of 86% and (n=332) carbapenem of present81% in was overtreatment superfluous: were regimens extensive of majority The infection. 3GC-resistant cultures for factors blood risk no had or patient the 3GC-resistant, and negative remained not was micro-organism cultured the because monotherapy), while this appeared unnecessary once culture results became available 12% of patients (n=480) received extensive empiric treatment (i.e. broader than 3GC- Empiric treatment andoutcomes a positivebloodculture withGram-negative bacteriathatare 3GC-resistant. will have a positive blood culture with Gram-negative bacteria and only 1.7 will have 9.0 culture, blood positive a have will 14.2 patients, 100 every Of BSI. of suspected initially patients of number total the on rate resistance this of impact the shows 1 Figure 1). (table 3GC-resistant were bacteria Gram-negative of 19% sample, our In ‘Dilution’ ofresistance these (n=70)were intrinsicallyresistant (e.g. 2.7% of all episodes (n=113) the cultured micro-organism was 3GC-resistant, most of with mostly positive, became cultures blood more or one episodes, 589 In (86%). negative remained cephalosporincultures blood episodes, most second-/third-generationIn (3GC). a 1).The received (table (n=3556) patients infection of bloodstream majority ofsuspected episodes 4140 identified We RESULTS hospital- SPSS Statistics (version22.0). age, IBM ICU-admission, with performed were analyses for statistical All score. CCI adjusting and infection, acquired events, adverse of occurrence and in- therapy, mortality), in-hospital empiric 30-day and 3-day,7-day overall, between (including mortality hospital associations assess to regression logistic used We resistance. increasing3GC- with complexity,change not proportionsdo these that assumed we model’s the Toconfine cohort. patient our on based was prevalence current the at Pseudomonas aeruginosa Escherichia coli Escherichia ). (40%). In (40%). All patients Tertiary hospital Teaching hospitals Patient characteristics No. of patients 4140 2960 1180 Male, n (%) 2303 (56) 1698 (57) 605 (51) Age, median (IQR) 67 (54-78) 67 (54-77) 69 (55-79) CCI, n (%) 0 1402 (34) 652 (22) 750 (64) 1-2 949 (23) 595 (20) 354 (30) 3-4 428 (10) 367 (12) 61 (5) >4 1361 (33) 1346 (46) 15 (1) Empiric therapy, n (%) 3GC (standard) 3556 (86) 2634 (89) 922 (78) 3GC+gentamicin 233 (6) 25 (1) 208 (18) Vancomycin+gentamicin 15 (0.4) 8 (0.3) 7 (1) Carbapenem 336 (8) 293 (10) 43 (4) Outcome, n (%) ICU-admission 653 (16) 443 (15) 210 (18) In-hospital mortality 310 (7) 198 (7) 112 (10) 3-day 68 45 23 7-day 119 73 46 30-day 259 158 101 Blood culture results, n (%) Positive culture 589 (14) 412 (14) 177 (15) E. coli 233 (40) 157 (38) 76 (43) S. aureus 52 (9) 34 (8) 18 (10) K. pneumoniae 45 (8) 29 (7) 16 (9) 8 Gram-negative pathogen 374 (9) 263 (9) 111 (9) 3GC-R (acquired) 42 (11) 32 (12) 10 (9) Total 3GC-R (acquired+intrinsic) 72 (19) 54 (21) 18 (16) 3GC-R pathogen 113 (3) 76 (3) 37 (3) E. coli 24 (21) 16 (21) 8 (22) Enterococcus spp. 36 (32) 18 (24) 18 (43) P. aeruginosa 16 (14) 9 (12) 7 (19)
TABLE 1 Population characteristics IQR: Interquartile range CCI: Charlson Comorbidity Index 3GC: second-/third-generation cephalosporin ICU: Intensive Care Unit 3GC-R: 3GC-resistant.
121 122 Chapter 8 curd neto ad aeoie Calo Cmriiy ne soe IU Itnie ae nt CI: Unit Care Intensive ICU: score. Index Comorbidity confidence interval Charlson categorized and infection acquired hospital- age, for adjusted reference, as therapy appropriate with analysis regression logistic of *Results TABLE 2 3GC: second-/third-generation cephalosporin FIGURE 1 treatment withcarbapenemoraminoglycosides, respectively) NNH:numberneededtoharm second-/third-generation 3GC: to attributable is that events adverse of Risk (percentage Percent ARP: Attributable score. Interval Confidence CI: Index Comorbidity Charlson monotherapycephalosporin Carba: Carbapenem ACT: therapycombination ratioaminoglycoside odds OR: categorized and ICU-admission *Results of logistic regression analysis with 3GC as reference, adjusted for age, hospital-acquired infection, TABLE 3 Adverse event, n(%) 30-day 7-day 3-day In-hospital mortality ICU-admission Total Total C. difficile Acute kidney injury
infection Empiric therapy andadverseevents Rates andoutcomesofappropriate, under- andovertreatment inempirictherapy Gram-negative resistance inpatientssuspectedofbloodstream infection(n=4140). 3GC Empiric treatment 247 (7) 62 (2) 185 (5) 179 86 49 216 (7) 512 (15) 3317 (80) Appropriate Antibiotic treatment, n(%) 34 (10) 14 (4) 20 (6) Carba 22 9 6 26 (8) 39 (11) 343 (8) Under 37 (15) 3 (1) 34 (14) ACT Carbapenem 1.62 (1.08-2.43) 2.60 (1.41-4.78) 1.26 (0.77-2.06) (95% CI) Adverse Event OR* 58 24 13 68 (14) 102 (21) 480 (12) Over 1.30 (0.81-2.06) 1.03 (0.51-2.08) 1.15 (0.48-2.71) 1.30 (0.84-1.99) 0.82 (0.57-1.18) Under outcome, OR*(95%CI) Association between antibiotictreatment and 31 (32) 58 (41) 13 (133) (NNH) ARP % 2.37 (1.58-3.55) 0.63 (0.19-2.10) 3.10 (2.01-4.66) (95% CI) Adverse Event OR* Aminoglycosides 3.04 (2.19-4.21) 2.41 (1.50-3.87) 2.18 (1.16-4.11) 2.81 (2.07-3.81) 1.40 (1.08-1.81) Over 53 (13) - 62 (12) (NNH) ARP % Adverse events 318 adverse events occurred in 306 patients, most often acute kidney injury. Extensive regimens were associated with more adverse events (table 3). There was no significant difference in occurrence of adverse events between appropriate treatment and overtreatment with either carbapenems (OR 1.00 95% CI 0.39-2.60) or aminoglycoside combination therapies (OR 1.27 95% CI 0.44-3.69).
Risk factors for 3GC-resistant bloodstream infection Of the 113 patients with 3GC-resistant BSI, 42% had at least one risk factor as currently defined by Dutch guidelines (i.e. use of cephalosporins and/or fluoroquinolones in the 30 days prior to infection, known carriage of cephalosporin-resistant micro-organisms in the 90 days prior to infection, hospital-acquired infection). Presence of any risk factor resulted in a PPV of 3.6% for 3GC-resistant BSI (full results in Supplementary Table 2).
Modelled outcomes of two approaches to adaptation of empiric treatment In light of these results, there are two approaches to adaptation of empiric treatment for patients suspected of BSI. If empiric treatment is adapted based on 3GC- resistance, as is currently the accepted approach, then empiric therapy would shift to a carbapenem or aminoglycoside combination therapy for all patients (approach ‘Extensive’). However, when including the dilution of resistance shown in figure 1, and 8 the limited predictive values of currently applied risk factors, empiric therapy would abandon risk stratification and consist of 3GC-monotherapy for all patients (approach ‘Standard’). Figure 2 shows how a modelled further increase in 3GC-resistance would affect overtreatment rates for the Extensive approach (panel A), and undertreatment rates for the Standard approach (Panel B). In our cohort, 1.01% (42 out of 4140) of all suspected BSI was caused by Gram-negatives with acquired 3GC-resistance, yielding a NNT of 99 (Panel A, ‡). This means that if we would follow the current practice of adapting empiric therapy based on 19% resistance among Gram-negatives, and thus apply the Extensive approach to all patients with suspected BSI, 98 patients would be overtreated to provide adequate empiric therapy to 1 patient.
123 124 Chapter 8 situation (1%undertreatment) ||WhenallGram-negatives are 3GC-resistant (11%undertreatment) with treated empirically 3GC-resistant¶Currentwith percentageinfection. patients equals of scenario Undertreatment this 3GC. in patients all ‘Standard’, approach B: Panel 9) (NNT Gram- 3GC-resistant all are §When negatives 98) (NNT situation ‡Current pathogens 3GC-resistant of coverage empiric achieve to all (NNT) treat to needed †When number shows line Dotted overtreatment). (89% 3GC-resistant overtreatment)are Gram-negatives (99% situation *Current aminoglycoside infection. (3GC)-resistant or cephalosporin carbapenem generation with treated empirically second-/third- without patients patients of percentage equals scenario therapy.this combination in Overtreatment all ‘Extensive’, approach A: Panel FIGURE 2 Modelled effectoftwoapproaches toadaptationofempirictreatment. DISCUSSION
In our multicentre cohort study, resistance to second-/third-generation cephalosporins (3GC) affected less than 2% of the total number of patients receiving empiric therapy because of suspected BSI. This was despite a nearly 20% prevalence of 3GC-resistance among Gram-negatives. We additionally confirmed that patients who are at an increased risk of 3GC-resistant BSI cannot be identified with current risk stratification algorithms.13
Clinicians are thus challenged to weigh the risk of empiric undertreatment against the side effects of empiric overtreatment. 21 Although the effects of (unnecessary) treatment with broader-spectrum antibiotics on the development of antibiotic resistance are well-known,9,22 fear of too narrow empiric treatment usually dominates, and side effects in individual patients are often brushed aside. In our cohort, empiric undertreatment rates (based on susceptibility results) were low (less than 2%). More importantly, empiric undertreatment was not associated with ICU admission or in- hospital mortality. The importance of rapid administration of antibiotics is largely undisputed, but the belief that early appropriate therapy improves survival in non- ICU patients, although intuitive, is often challenged and has been disproved by several studies.3,23-30 At the same time, adverse events of extensive regimens were frequent. As shown before, carbapenems and aminoglycosides were associated 8 with an increased risk of Clostridium difficile infections5 (odds ratio 2.65) and acute kidney injury6,7 (odds ratio 2.76), respectively. More importantly, these regimens were deemed superfluous in as many as eight to nine out of ten prescriptions, which means that the larger part of adverse events may have been prevented.
Our study thus reveals a problem in our current thinking about empiric antibiotic treatment. The effects of extensive treatment are usually underestimated, while the effects of empiric undertreatment seem to be overestimated. Moreover, patients suspected of BSI encompass a large and diverse group; there are many possible causative pathogens and blood cultures often remain negative. 13 This causes a phenomenon we have named ‘dilution’ of resistance. Intuitively and historically, guidelines for empiric antibiotic treatment are adjusted to the susceptibility of a single most likely pathogen,11 with 10-20% resistance generally considered a breaking point.4 Although we naturally respond well to this approach, adjustment could also be based on the susceptibility of several likely causes combined, as the issues with cut-off percentages for single pathogens have been pointed out before. 12,13 Our study demonstrates that in the example of BSI, adjusting for a single group of most likely pathogens would mean that empiric therapy guidelines may soon be adjusted to 125 126 Chapter 8 value. predictive low very a has this that confirms study our bacteria, 3GC-resistant with infection for factor risk a considered often is infection hospital-acquired Although severity ofillnessscores (suchas(q)SOFA or(q)PITT) are usuallynotincluded. BSI, of treatment empiric for guidelines in while treatment), empiric of choice the but pathogen, severity of illness, estimated through scoring systems such likely as PSI or CURB-65, guides most the of susceptibility the (not pneumonia for guidelines antibiotic in practice common already is approach this Interestingly,category. this in undertreatment empiric of consequences severe more the reflecting patients, ill severelymost the in regimens extensive use physicians that suggests This infections. 3GC-resistant for factors risk of regardless ICU-admission, towards trend a as well mortality, as and overtreatment between association the was finding interesting an However,presentation. upon illness of severity the on information have not did we that is limitation important An decision-making. clinical of and studies of limitation general a is this Unfortunately, BSI. 3GC-resistant of underestimation caused have may which pathogens, resistant by caused been have may 80-96%. BSI culture-negative from the varies sensitivity BSI, of diagnosis the for method main the remain cultures blood Although unnecessary. as labelled been incorrectly have may regimens extensive the of some therefore included, been have suspected. may negatives is BSI which in patients Patients who did not have BSI, but a respiratory or urinary include tract infection with Gram- to aimed We severity. comorbidity underestimatedhave may which information, costing activity-based using calculated hospital, one In retrieved,be thereforenot scorescould Index ICD-codes wereComorbidity Charlson factors. risk our on In data design. incomplete in retrospective resulted a have may of this limitations study, general the to subject is study Our resistant strains are more prevalent. the wheresettings micro-organismsand as other infections, other to also but Netherlands, such country low-resistance is a in resistance BSI Gram-negative of to ‘dilution’ applicable only of not concept The preserved. therapy, be empiric may choosing regimens to extensive approach different a with that indicates study Our there is an urgent need to preserve what is left of our precious antimicrobial arsenal. antibiotic resistance, combined with the stagnant development of new antimicrobials, ever-increasingthe With paradigm. antibiotics empiric the of problem the illustrates Our study has strengths and limitations. To our knowledge, this is the first study that lead tovastovertreatment. will which patients, all for therapies combination aminoglycoside or carbapenems 13 We therefore included both community- and hospital-acquired infections in infections hospital-acquired and community- both included therefore We 31 oe of Some our study; this may be different in other settings. In addition, we did not quantify the (long-term) impact of the adverse events. However, Clostridium difficile infections have been extensively linked to increased mortality and increased costs 32 and acute kidney injury, even if reversible, can contribute to long-term morbidity and mortality. 33 In current guidelines, 3GC-resistance is defined as extended-spectrum beta-lactamase (ESBL)-production, which comprises micro-organisms that have acquired 3GC- resistance. Our model therefore focused on the impact of acquired resistance. One could argue that when acquired resistance in Gram-negatives increases, prevalence of intrinsically resistant micro-organisms, such as Pseudomonas aeruginosa, will increase as well.
We developed a model based on characteristics of likelihood ratios. 19,20 To confine complexity, we assumed a set ratio between patients with and without risk factors, even with increasing incidence of resistance. This is a simplification of reality, as the prevalence of risk factors, especially prior colonization, will likely increase with rising resistance. Our model’s predictions will therefore become less accurate further into the future. However, both simplification and decreasing accuracy are inherent to mathematical models. Most importantly, these data are meant to illustrate the phenomenon of dilution, not to predict future resistance rates.
It is important to note that it is not our intention to propose completely abandoning 8 extensive therapy for patients suspected of BSI, but merely to challenge the way we think about adjustment of empiric therapy. As mentioned above, empiric therapy constitutes a calculated risk; the risk of empiric undertreatment versus adverse events of empiric overtreatment. Our aim was to show how resistance of selected micro- organisms does not translate well to the individual patient. In addition, we should remark that we address empiric therapy only. Empiric antibiotic treatment should always be adjusted to definitive treatment as soon as susceptibility results become available, as proposed before.24,28
Our study shows that resistance rates of a single group of possible causative pathogens have little impact on the risk of undertreatment. Efforts to improve risk stratification are needed to better guide empiric treatment decisions, 34 but until then, the practice of adapting empiric therapy based on resistance of the most likely pathogens, without taking into account that this resistance only occurs in a very small proportion of patients suspected of BSI, may lead to high overtreatment rates with an associated increase in important adverse events.
127 128 Chapter 8 Formula forawasderivedfrom Formulas fortheindividualcells 3GC: third-generation cephalosporins TABLE S1 SUPPLEMENTARY MATERIAL Amsterdam, TheNetherlands)fortheircontributions tothedatacollection. The authors would like to thank Cees van der Mark and Ruth Stoffels (OLVG Amsterdam, ACKNOWLEDGEMENTS Risk FactorsRisk - FactorsRisk + . Contingencytablewithmodelformulas rn c a 3GC resistant + (1-r)n d b 3GC resistant - n (a+b+c+d) n-x x Prevalence in patients with 3GC-resistant blood culture n (%) Positive predictive value (%) Overall prevalence Acquired and intrinsic Acquired resistance Acquired and intrinsic Acquired Risk factor of risk factor n (%) resistance (113) only (43) resistance resistance only Prior colonization 102 (2) 9 (8) 8 (19) 8.8 7.8 (90 days) Prior use of antibiotics 256 (6) 15 (13) 5 (12) 5.9 2.0 (30 days) Hospital-acquired BSI 1057 (26) 30 (27) 12 (28) 2.8 1.1 Prior colonization or 340 (8) 23 (20) 12 (28) 6.8 3.9 prior use of antibiotics Prior colonization or prior use of antibiotics 1341 (32) 48 (42) 21 (49) 3.6 1.6 or hospital-acquired BSI
TABLE S2. Prevalence and positive predictive values of risk factors for second/third-generation cephalosporin (3GC)-resistant bloodstream infection (BSI) Rates were calculated for all 3GC-resistant BSI, and for BSI caused by Gram-negative bacteria with acquired resistance only
8
129 130 Chapter 8 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 REFERENCES bacteraemia caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae andpatient beta-lactamase-producing causedbybacteraemia extended-spectrum Hospitalized Patients. JAMA Med Intern Dis Infect Therapy inPatients With Study. AProspective Cohort Severe Shock: andSeptic Sepsis Observational Clin (1): CD003344. lactam-aminoglycoside antibiotic combination therapy for sepsis. Antimicrob Chemother for the treatment of sepsis: systematic review and meta-analysis of randomized controlled trials. J sepsis. SWAB, Amsterdam, Netherlands 2015 coli study. Escherichia afive-year bacteraemia: DisInfect Int J beta-lactamase-producing spectrum resistance ECDC;2015. infections 2014.Stockholm: andhealthcare-associated andEurope. America in North Infect ClinMicrobiol tests. 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Epidemiology, Biostatistics, andPreventive 3rd Medicine ed: ElsevierHealthSciences; 2007. M,PompeiCharlson P, C.Anewmethod of classifyingprognostic Mackenzie in comorbidity Ales K, andclassifying acute R,KellumJA,Ronco C.Defining Bellomo renal failure: from to advocacy consensus European Centre for Disease Prevention andControl. Point prevalence ofhealthcare-associated survey Antimicrobial of microorganisms: distributions wildtype European Committee onAntimicrobial Marchick JM, Heffner MR,JonesAE. Etiology ofillnessinpatientsAC, Horton withsevere sepsisadmitted Rottier WC, Bamberg YRP, JW, Dorigo-Zetsma Van LindenPD, Der HSM,Bonten Ammerlaan MJM. C,Ridgway J, Hebert Vekhter B, Brown EC, Weber A.Demonstration SG,Robicsek oftheweighted- Dellit Mcgowan RC, JE,TH, Owens Jr. Rottier HS,BontenWC, Ammerlaan MJ. JP.Burke theballoon? Antibiotic resistance--squeezing Tamma PD, Avdic E, LiDX, Cosgrove Dzintars K, SE. Association ofAdverse Events With Antibiotic Use in Ong DSY, Frencken JF, Klouwenberg PMC Klein Paul M,LadorA,Grozinsky-Glasberg S,Leibovici antibiotic monotherapy lactam versus L.Beta beta Shiber S, Yahav D, Avni T, Leibovici inhibitors L,Paul versus carbapenems M.beta-Lactam/beta-lactamase Stichtingwerkgroepantibioticabeleid. SWAB guidelinesfor therapy antibacterial ofadultpatients with B,Denis M,Donay Lafaurie JL European Centre for DiseasePrevention andControl. -Antimicrobial Annual epidemiological report Goto M,Al-Hasan MN.Overall burden ofbloodstream infectionandnosocomial bloodstream infection ; 39:1-6. 2017 2012 ; 64(12):1731-6. ; 33(4):381-8. 2015 J Antimicrob Chemother 2003 etal ; 70(1):41-7. ; 26(5):111-3. . Prevalence, onclinicaloutcome factors, ofextended- risk andimpact et al 2010 Effects of confounders andintermediates ontheassociation of 2017 2007 . Infectious Diseases Society of America and the Society for andtheSociety ofAmerica DiseasesSociety Infectious . . ; 44(2):159-77. etal 2013 2012 . Short-Course Adjunctive asEmpirical Gentamicin Short-Course 2007 JAMA ; 19(6):501-9. ; 67(6):1311-20. ; 33(3):409-13. 1998 2010 ; 280(14):1270-1. Cochrane Database Syst Rev ; 50(6):814-20. 1987 2015 Infect ControlInfect Hosp ; 40. ; 60:1622-30. 2014 ; 21 Paterson DL, Rice LB. Empirical antibiotic choice for the seriously ill patient: are minimization of selection of resistant organisms and maximization of individual outcome mutually exclusive? Clin Infect Dis 2003; 36(8): 1006-12. 22 Mclaughlin M, Advincula MR, Malczynski M, Qi C, Bolon M, Scheetz MH. Correlations of antibiotic use and carbapenem resistance in enterobacteriaceae. Antimicrob Agents Chemother 2013; 57(10): 5131-3. 23 Beuving J, Wolffs PF, Hansen WL et al. 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131 Observe due measure, for right timing is in all things the most important factor - Hesiod CHAPTER 9 Indwelling time of peripherally inserted central catheters and incidence of bloodstream infections in haematology patients: a cohort study
Martine G. Caris* Nick A. de Jonge* Henk J. Punt Dorien M. Salet 9 Vincent M.T. de Jong Birgit I. Lissenberg-Witte Sonja Zweegman Christina M.J.E. Vandenbroucke-Grauls Michiel A. van Agtmael Jeroen J.W.M. Janssen
*These authors contributed equally
Submitted for publication 134 Chapter 9 this population. in CLABSI prevent to unlikely is therefore PICCs of replacement time Routine thereafter. indwelling with increase to appear not does but PICC-placement, after days CONCLUSIONS but a constant hazard with indwelling time thereafter (estimated shape parameter 1). increasingan parametershowed hazardshape cumulative (estimated time 1.8),over function hazard cumulative estimated the days, 28 first the For days. catheter 1000 Median indwelling time was 26 days (range 0-385) and CLABSI incidence was 4.0 per RESULTS PICC of days 28 after indwelling time. and to up period the for separately estimated was hazard and Weibull CLABSI distribution. As a the curve showed follow a change of in to slope after assumed 28 days, cumulative was hazard function hazard cumulative and The factors. incidence risk determined cumulative calculated We assessed. was receiving PICCs between 2013-2015. Occurrence of CLABSI based on CDC definitions METHODS preventing CLABSI inhaematologypatients. in aid could replacement PICC scheduled whether address thus and CLABSI of risk OBJECTIVES ABSTRACT 455 PICCs were placed in 370 patients, comprising 19063 catheter days. catheter 19063 comprising patients, 370 in placed were PICCs 455 utcnr rtopcie oot td aog amtlg patients haematology among study cohort retrospective Multicentre e ie t ass wehr ogr IC nwlig ie increases time indwelling PICC longer whether assess to aimed We Our study shows that risk of CLABSI increases during the first 28 first the during increases CLABSI of risk that shows study Our INTRODUCTION
A recurring dilemma in clinical practice is whether we should routinely replace central venous catheters (CVCs) to prevent infections or wait and see if one occurs. In haematology patients, peripherally inserted central catheters (PICCs) are frequently used to provide long-term venous access, as they are easier and safer to insert than other types of CVCs.1,2 However, like other CVCs, PICCs pose an important, albeit smaller risk for central line-associated bloodstream infection (CLABSI),3-6 which may lead to hospitalization and a considerable burden of antibiotic therapy.4 Previous studies have shown that bacterial colonization of intravascular catheters increases with prolonged use, leading to increasing risk of infection with longer indwelling time. 5,7,8 This suggests that routine replacement of PICCs may prevent CLABSI.
The Center for Disease Control and Prevention (CDC) currently advises against routine replacement of CVCs to prevent bloodstream infections, based on results of randomized studies in critically ill patients.2,9-11 Unfortunately, results of these studies are not easily translated to the haematology population, as CVCs were replaced within several days, whereas PICCs can remain in situ for weeks or even months. In addition, none of the studies investigated PICCs as type of CVC, even though risks of replacement are much lower. Moreover, incidence of CLABSI is higher in aggressive haematologic malignancies,12 acute leukaemia in particular.13 Pre-emptive CVC replacement could thus be beneficial, but studies in this population are lacking.
The value of scheduled replacement of PICCs to reduce risk of infection in patients with 9 haematological malignancies therefore remains an important but unresolved issue. We aimed to assess if and when scheduled replacement of PICCs in these patients should take place.
METHODS
This cohort study was conducted between June 2013 and June 2015 at the Amsterdam UMC, location VUmc, a tertiary care centre, and affiliated teaching hospitals in the Netherlands. All PICCs inserted at the department of haematology in VUmc were registered in a prospective database designed for quality purposes. Data included previously reported risk factors for CLABSI such as number of catheter days, side of insertion, time needed for insertion, need for repositioning and number of lumens, as well as reasons for removal. Patient data included age, gender, primary haematological diagnosis, use of total parenteral nutrition, highest dose of prednisone in the week 135 136 Chapter 9 line. CLABSI treatment witheitherantibiotics,PICCremoval, orboth, wasregistered. Barrier Mucosal Injury-LCBI (MBI-LCBI) and from infections CLABSI, as bloodstreamthese infections are secondary not related excluded to the we central recommendations, CDC (temperature symptoms or signs >38.0°C, chills or systolic blood pressure clinical <90mmHg) (LCBI 2, see morealso figure 1). Following or one of presence the in commensal common a or 1) (LCBI pathogen recognized a either with (LCBI), infection bloodstream laboratory-confirmed a as CLABSI defines module TThis (2015). Infection)’ Bloodstream Line-Associated Non-central and Infection Bloodstream Line-Associated (Central Event CLABSI was defined using the CDC Device-associated Module BSI ‘Bloodstream Infection Definitions patients withacutelymphoblasticleukaemiaoraplasticanaemia. obtained twice weekly in patients with GVHD treated with high dose corticosteroids, and only.fluconazole cultures were blood protocol surveillance hospital Accordingroutine to and ciprofloxacin with prophylaxis received patients other All neutropenia. of recovery until and chemotherapy oral of start from prophylaxis antifungal as fluconazole and tobramycin) or pheneticillin, amoxicillin (ciprofloxacin, prophylaxis antibacterial received days 7 than more of neutropenia expected with patients All needed. if earlier or weekly replaced were valve open-ended and dressing The site. insertion the seal to used was was routinely replaced every 3 weeks. A chlorhexidine coated dressing (Tegaderm HCG®) for PICC placements. Throughout the study period, StatLock® was used for fixation which disinfectant as tincture iodine replaced chlorhexidine 2014, study.January our In during used not were catheters antimicrobial and therapy lock Antimicrobial used. were lock heparin PowerPICCswith (Bionector®) valve open-ended an with systems) access (BARD chest through assessed radiography; was incorrectly positioned catheters position were replaced PICC by an nurses. intervention radiologist. trained by inserted were PICCs All Catheter placementandpost-insertion care were patients non-haematology in use excluded from theanalysis. for inserted PICCs used. were PICCs than CVCs of types other No for care. supportive and used transplantations cell chemotherapy,were stem inserted PICCs hospital. that from obtained was data situ, in was line PICC- a while transferred were patients If infusion. cell stem after day the on hospital autologous stem cell transplantation in our centre, are transferred to undergoinga regional teaching patients most reasons, logistical For records. patient from retrospectively 3 days thereafter), as proposed by the CDC. Patient data and culture data were collected days within a seven-day window around a CLABSI event (i.e. 3 days before the event and neutrophil count or total white blood cell count <500 cells/mm absolute an as defined was Neutropenia neutropenia. of presence and CLABSI, before 3 on at least two separate Statistical analysis We applied descriptive statistics as appropriate. Incidence of CLABSI and DVT was calculated per 1000 catheter days. Median time to CLABSI and cumulative incidence of CLABSI were assessed by Kaplan Meier curves and risk factors were investigated using a Cox proportional hazards model. Clinically relevant covariates were retained at the p<0.1 significance level. Using backward elimination, variables with p-values <0.05 were included in the model. To adjust for clustering, sensitivity analyses were performed to assess influence of PICC-line rank on these associations. These analyses were performed with IBM SPSS Statistics (version 22.0). To assess whether the risk of CLABSI increases with longer catheter indwelling time, we investigated the cumulative hazard for two different time intervals, using R, version 3.4.2 (R foundation for Statistical Computing, Vienna, Austria). The cumulative hazard function was assumed to follow a Weibull distribution, which is a commonly used distribution for time-to-event variables.
RESULTS
We evaluated 455 PICC episodes in 352 patients, comprising 18.977 catheter days. Patient and PICC episode characteristics are summarized in table 1. Nearly half of all patients underwent haematopoietic stem cell transplantation (HSCT), mostly autologous. A double lumen PICC was placed in the right arm in the majority of patients. Most PICCs were in place for approximately one month. Due to the data collection process, we had no missing data. 9 Infectious complications CLABSI occurred in 17% of PICC episodes (77/455), with an incidence of 4.1 per 1000 catheter days (Figure 1). Median time to CLABSI was 33 days (range 18-158) (Figure 2, panel A). Fifty-one percent of CLABSI cases occurred during neutropenia and 40% occurred in the outpatient setting; these were all symptomatic. In 33% of the outpatient CLABSI events patients had received prophylactic antibiotics. The majority of CLABSIs was caused by a recognized pathogen (LCBI1) (Figure 1). Gram-negative pathogens accounted for 62% of bloodstream infections (Table 2). In one third of these episodes the pathogen was resistant against ciprofloxacin or tobramycin used as prophylaxis (data not shown). Staphylococcus epidermidis and Enterococcus faecium were the most prevalent Gram-positive bacteria. If CLABSI occurred, the PICC was removed in 64 of 77 CLABSI events (83%) because of proven or suspected CLABSI. The median time to PICC-removal was 4 days (IQR 2-14).
137 138 Chapter 9 ◊ 9episodeshadmissingdata*20 hadmissingdata. # TABLE 1 Supportive care Supportive Chemotherapy HSCT, n(%) diagnosis, vs. n(%inCLABSI Primary No CLABSI) Gender, Age, Number ofepisodes Patient characteristics Total parenteral nutrition, n(%) Catheter days PICC n(%) linerank, Number oflumens, n(%) inright arm,n(%) Insertion Repositioning after placement, n(%)* Duration ofplacement inminutes, PICC characteristics Blastic Plasmocytoid Dendritic Cell Neoplasm (n=2), Systemic sclerosis (n=1) and Hairy Cell Leukaemia (n=1) Duration (mediandays, range) mean median Third ormore Second First Allogeneic Autologous Other Chronic Lymphocytic Leukaemia Myeloproliferative neoplasms Chronic Leukaemia Myelomonocytic Chronic Myeloid Leukaemia Aplastic Anaemia Hodgkin Lymphoma Myelodysplastic Syndrome Acute Lymphoblastic Leukaemia Non-Hodgkin Lymphoma Acute Myeloid Leukaemia Multiple myeloma Triple lumen lumen Double lumen Single median # male
(range) Population characteristics (range) (%) median (range)◊
30 (20-180) 58 (18-78) 10 (1-185) 26 (0-385) 281 (62) 343 (75) 368 (81) 367 (81) 126 (28) 218 (48) 164 (75) 219 (48) 52 (11) 89 (20) 53 (12) 55 (25) 23 (5) 34 (8) 16 (4) 103 118 122 455 All 10 11 15 46 46 ¶ Χ 8 4 5 6 7 2 notsignificant 30(30-75) 57 (18-78) 11 (1-120) 25 (0-385) 12 (23) CLABSI CLABSI 14 (30) 14 (14) 25 (21) 44 (56) 23 (26) 53 (16) 10 (29) 53 (14) 14 (26) 60 (16) 18 (14) 61 (28) 6 (60) 3 (27) 4 (27) 4 (25) 7 (13) 12 (6) 1 (20) 2 (29) 8 (7) 1 (5) 5 (3) 77 40 0 0 0 ¶ 30 (20-180) No CLABSI 58 (18-78) 41 (4-320) 13 (2-99) 114 (93) 236 (62) 290 (84) 315 (86) 307 (84) 108 (86) 157 (72) 159 (97) 207 (94) 40 (77) 8 (100) 11 (13) 32 (70) 89 (86) 93 (79) 22 (94) 66 (74) 24 (71) 39 (74) 12 (75) 48 (87) 4 (100) 6 (100) 4 (40) 8 (13) 4 (80) 5 (71) 378 44 ¶ PICCs placed between June 2013-June 2015 (n=532) 74 episodes excluded 63 non-hematology patients 9 not first PICC during study period PICCs placed between 1 line removed same day due to progression June 2013-June 2015 (n=458) Date of removal missing (n=3)
PICCs-episodes included (n=455)
Positive blood culture(s) (n=167)
Pathogen Commensal (n=100) (n=67)
No fever, chills or hypotension (n=48)
Second culture Different organism (n=5) Secondary BSII MBI-LCBI LCBI 1 LCBI 2 No LCBI 2 More than 24 hours after first culture (n=2) (n=5) (n=35) (n=60) (n=17) (n=50) Unknown location (n=1)
CLABSI (n=77)
FIGURE 1 Infectious complications of PICCs in the study population BSI Bloodstream infection; °Secondary BSI the same micro-organism was found in cultures from a different site; LCBI Laboratory Confirmed BSI; MBI-LCBI Mucosal Barrier Injury-LCBI 9 Risk factors for CLABSI Univariate analysis revealed that ALL, aplastic anaemia, any stem cell transplantation, but autologous SCT in particular, induction chemotherapy, higher number of lumens and catheter indwelling time were found to have a significant relation with CLABSI. The multivariate model showed a significant association between aplastic anaemia and occurrence of CLABSI (HR 6.48 [95% CI 2.76-15.18]). Autologous stem cell transplantation showed an inverse association with the occurrence of CLABSI (HR 0.24 [95% CI 0.10-0.61] (table 2; figure 2, panel A). Sensitivity analysis revealed no effect of line rank on the associations.
Figure 2, panel B shows the cumulative hazard for CLABSI, stratified for aplastic anaemia and autologous SCT, respectively. Panel C shows the cumulative hazard curve, which was assumed to follow the aforementioned Weibull distribution with scale parameter l and shape parameter p. Curves showed a decrease in slope after 28 days, we therefore estimated the parameters l and p separately for the period 139 140 Chapter 9 ** In14episodes,bloodcultures showed 2different pathogens. paucimobilis, Staphylococcus haemolyticus, Streptococcus pneumoniae Ochrobactrum radiobacter,Rhizobium oryzihabitans, Pseudomonas acnes, Propionibacteriumanthropic, Sphingomonas subflava, Neisseria chelonae, Mycobacterium spp., Micrococcus haemolysins, Gemella * TABLE 2 thereafter. (41/140) 29% and (36/238) 15% was days 28 before occurring CLABSI of Incidence blue). dark in curve linear the by shown (as time over hazard constant a indicates This 1. to set was parameter shape the while 0.0058 by estimated was parameter by the exponential curve in light blue). For the second period after 28 days, the scale increasing hazard (i.e. instantaneous risk of an CLABSI) with during the corresponds firstThis 28 days1.8. (as shownby parameter shape the and 0.11 by estimated was parameter scale the period, first the For days. 28 after period the and days 28 to up All ** Gram negative Gram positive Pathogen
Chrysobacterium indologenes, Citrobacter freundii, Enterococcus casselflavius, Fusarium dimerum, Fusarium casselflavius, Enterococcus freundii, Citrobacter indologenes, Chrysobacterium Other (alln=1)* Other Brevibacterium casei Brevundimonas diminuta Pantoea spp. putida Pseudomonas Klebsiella pneumoniae Achromobacter spp. Escherichia coli Serratia marcescens fluorescensPseudomonas Acinetobacter spp. aeruginosa Pseudomonas Stenotrophomonas maltophilia Enterococcus faecalis Enterobacter cloacae/asburiae Rothia mucilaginosa Staphylococcus aureus Enterococcus faecium Staphylococcus epidermidis Cultured pathogensinCLABSI 2 2 (2) 2 (2) 2 (2) 3 (3) 3 (3) 4 (4) 5 (5) 6 (7) 7 (8) 55 (60) 3 (3) 2 (2) 3 (3) 3 (3) 7 (8) 18 (20) 36 (40) more bloodcultures, n(%) inwhichpathogenNumber ofCLABSI was present in1or 91 15 2 2 Panel A Panel B Cumulative incidence of CLABSI, stratified analysis Cumulative hazard of CLABSI, stratified analysis
9
Panel C Cumulative hazard of CLABSI, overall analysis
FIGURE 2 Cumulative incidence and cumulative hazard of CLABSI. autoSCT: autologous stem cell transplantation, AA: aplastic anaemia
141 142 Chapter 9 might alsopartlyexplainthisfinding. which prophylaxis, standard against resistance Gram- showed isolates of culture blood thirdnegative one Also, pathogens. Gram-negative of percentage higher a explain could which CLABSI, as MBI-LCBI labelling incorrectly to led have may This MBI-LCBI. and CLABSI primary between distinguish to difficult thereforebe can It bacteraemia. of date the after and before days three the during present was neutropenia if or disease barrier disruptioncanonlybediagnosedduringgrade 3or4intestinalgraft versushost mucosal from infection bloodstream secondary because strict, quite is (MBI-LCBI) tract gastrointestinal the from infection bloodstream secondary of definition The CLABSI. of bacteria, Gram-negative in increase coagulase negative mostly (55%, infection bloodstream for cause common most the as pathogens positive Gram- reporting patients haematology in studies epidemiologic earlier with contrast in is This antibiotics. prophylactic received patients to all though even 0.17 pathogens, negative of rates (incidence days). PICCs catheter with 6.61/1000 patients haematology in studies with line in previous is which days, catheter 1000 per 4.1 was study our in incidence CLABSI hazard ofCLABSI after28days. longer without developing CLABSI. This could possibly explain the decreasing cumulative to prone more PICC areretain the to treatment areable intensive less with patients while on, CLABSIearly treatment intensive receiving patients that explain could effects Finally,selection bloodstream. the to translocation bacterial of risk the decrease might whichwithdrawal), blood and administration drug for (e.g. intensively less used is PICC the setting outpatient the In outpatients. included also study our whereas inpatients, PICCs. include not did or respectively) days, 14 (median investigated neonates, time. indwelling longer with increases infection of risk the is in contrast with previous studies that showed non-linear colonization of CVCs, i.e. that counterproductive.This be even may and infections preventPICC-associated to unlikely usually remain in situ for at least several weeks, this suggests that routine replacement is cumulative hazard flattens upon longer indwelling time. As PICCs in haematology patients the risk of PICC-associated CLABSI increases progressively during the first 28 days, but the malignancies, haematological with patients in that shows study multicentrecohort This DISCUSSION 5 maximum of 15 days in 93% of patients, of 93% in days 15 of maximum Staphylococcus 5 and intensive care patients, 6,13-15 n u chr, 7 o CAS wr de o Gram- to due were CLABSI of 57% cohort, our In (CNS)). Although a more recent study suggested an 16 this shift could also be due to the CDC-definition the to due be also could shift this 7,8 n diin tee tde sll fcsd on focused solely studies these addition, In 7,8 had much shorter indwelling times 5,7,8 7 However, these studies these However, and median 4-7 days, 4-7 median and 8
We identified aplastic anaemia (AA) as an important risk factor for CLABSI. Patients with AA typically have prolonged neutropenia and receive immunosuppressive therapy that includes high doses of steroids. Steroids, in addition to neutropenia, could hamper skin barrier function at the insertion site, which could make these patients more prone to CLABSI. As mentioned before, surveillance blood cultures were obtained in these patients, which may have led to higher detection of bacteraemia. However, this is less likely with the crude CLABSI definitions, in which positive blood cultures with common commensal bacteria (such as CNS) are only considered CLABSI if clinical symptoms (fever, chills, and/or hypotension) are present. Autologous stem cell transplant recipients on the other hand appeared to have a lower risk of CLABSI, which may be due to the short duration of neutropenia during PICC indwelling time.
Although total parenteral nutrition (TPN) has previously been described as a risk factor for CLABSI in different subgroups such as trauma and ICU patients, and patients with gastro-intestinal malignancies, we did not find this association in our cohort. 17,18 In one study among oncology patients receiving long term parenteral nutrition at home, median indwelling time was 112 days, CLABSI incidence rate was 0.6 per 1000 ‘home TPN days’ versus 0.35 per 1000 overall catheter days, 19 suggesting that TPN is a possible risk factor for CLABSI. In haematological patients, TPN is used to overcome alimentary problems due to nausea and mucositis. Compared to non-haematological patients, TPN is used for a relatively short period of time (a median duration of 9.5 days in our cohort) (Table 1), which may explain these differences. Unfortunately, most studies report TPN as a binary variable and do not report median duration of TPN. 9
Our study has strengths and limitations. To our knowledge, this is the first study to investigate whether the risk of PICC-associated CLABSI increases with longer indwelling time in a high-risk population of haematology patients. Our cohort represents a diverse group with respect to age, gender, and primary haematological diagnosis, and included a large cohort over several years in multiple hospitals. Therefore our findings can be extrapolated to the general haematology population. Our study is subject to the general limitations of an observational design, which means that information bias may have been introduced: although most of our database was kept prospectively, post-insertion data from other hospitals was collected retrospectively, which may have led to misclassification. We assessed the occurrence of CLABSI based on CDC-definitions, which is a rigorous method and therefore adds to generalizability. However, as the CDC guideline was mainly developed for surveillance purposes, definitions of CLABSI are rather stringent, which means that clinically suspected catheter-related infections without positive blood cultures are not reported. As 143 144 Chapter 9 The authors would like to thank the PICC-team nurses for their support of this study. ACKNOWLEDGEMENTS recommended inthispopulation. be not therefore should PICCs of replacement Routine infections. PICC-associated preventing in aid not would thereafter replacement routine while risk, increased of period the prolonging thereby curve, the of start the to patients reset only would We can therefore hypothesise that replacing PICCs before 28 days, e.g. after 2 weeks, thereafter,remainsconstant weeks. 4 first the increasereducedafter risk suggesting hazard CLABSI but PICC-placement, after days 28 first the during increases sharply CLABSI of risk malignancies, haematological with patients in that shows study Our method mayhaveunderestimated clinicallyrelevant incidence of CLABSI. suspected
LBI s n motn die o atboi ue n lncl rcie this practice, clinical in use antibiotic of driver important an is CLABSI REFERENCES
1 Johansson E, Hammarskjold F, Lundberg D, Arnlind MH. Advantages and disadvantages of peripherally inserted central venous catheters (PICC) compared to other central venous lines: a systematic review of the literature. Acta Oncol 2013; 52(5): 886-92. 2 Cobb DK, High KP, Sawyer RG et al. A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters. N Engl J Med 1992; 327(15): 1062-8. 3 Safdar N, Maki DG. Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest 2005; 128(2): 489-95. 4 Mermel LA, Allon M, Bouza E et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 49(1): 1-45. 5 Milstone AM, Reich NG, Advani S et al. Catheter dwell time and CLABSIs in neonates with PICCs: a multicenter cohort study. Pediatrics 2013; 132(6): e1609-15. 6 Zakhour R, Hachem R, Alawami HM et al. Comparing catheter-related bloodstream infections in pediatric and adult cancer patients. Pediatr Blood Cancer 2017; 64(10). 7 Mclaws ML, Berry G. Nonuniform risk of bloodstream infection with increasing central venous catheter- days. Infect Control Hosp Epidemiol 2005; 26(8): 715-9. 8 Lucet JC, Bouadma L Fau - Zahar J-R, Zahar Jr Fau - Schwebel C et al. Infectious risk associated with arterial catheters compared with central venous catheters. (1530-0293 (Electronic)). 9 Eyer S, Brummitt C, Crossley K, Siegel R, Cerra F. Catheter-related sepsis: prospective, randomized study of three methods of long-term catheter maintenance. Crit Care Med 1990; 18(10): 1073-9. 10 Cook D, Randolph A, Kernerman P et al. Central venous catheter replacement strategies: a systematic review of the literature. Crit Care Med 1997; 25(8): 1417-24. 11 Berthelot P, Zeni F, Pain P et al. [Catheter infection in intensive care: influence of systematic replacement of central venous catheters on a guide wire every 4 days]. Presse Med 1997; 26(23): 1089-94. 12 Mollee P, Jones M, Stackelroth J et al. Catheter-associated bloodstream infection incidence and risk factors in adults with cancer: a prospective cohort study. J Hosp Infect 2011; 78(1): 26-30. 13 Morano SG, Latagliata R, Girmenia C et al. Catheter-associated bloodstream infections and thrombotic risk in hematologic patients with peripherally inserted central catheters (PICC). Support Care Cancer 9 2015; 23(11): 3289-95. 14 Paras-Bravo P, Paz-Zulueta M, Sarabia-Lavin R et al. Complications of Peripherally Inserted Central Venous Catheters: A Retrospective Cohort Study. PLoS One 2016; 11(9): e0162479. 15 Zakhour R, Chaftari AM, Raad, Ii. Catheter-related infections in patients with haematological malignancies: novel preventive and therapeutic strategies. Lancet Infect Dis 2016; 16(11): e241-e50. 16 Worth LJ, Seymour JF, Slavin MA. Infective and thrombotic complications of central venous catheters in patients with hematological malignancy: prospective evaluation of nontunneled devices. Support Care Cancer 2009; 17(7): 811-8. 17 Chopra V, Ratz D, Kuhn L, Lopus T, Chenoweth C, Krein S. PICC-associated Bloodstream Infections: Prevalence, Patterns, and Predictors. The American Journal of Medicine 2014; 127(4): 319-28. 18 Herc E, Patel P, Washer LL, Conlon A, Flanders SA, Chopra V. A Model to Predict Central-Line–Associated Bloodstream Infection Among Patients With Peripherally Inserted Central Catheters: The MPC Score. Infection Control & Hospital Epidemiology 2017; 38(10): 1155-66. 19 Cotogni P, Pittiruti M, Barbero C, Monge T, Palmo A, Boggio Bertinet D. Catheter-related complications in cancer patients on home parenteral nutrition: a prospective study of over 51,000 catheter days. JPEN J Parenter Enteral Nutr 2013; 37(3): 375-83.
145 The future is uncertain, but this uncertainty is at the very heart of human creativity - Ilya Romanovich Prigogine CHAPTER 10 Summary of main findings, general discussion and future directions
10 148 Chapter 10 performed a before-after trial to measure whether compliance had improved after improved had compliance whether measure to trial before-after a performed We compliance). as known (also guidelines hygiene hand to adherence improve to one of the CIA’s projects, in which we launched an extensive hospital-wide campaign this. achieving in role important an play to seems that factors the of one is culture Safety change. behaviour requires adherence guideline improving that recognized increasingly is It PART I–Behavioural interventions guidelines? Thisquestionisaddressed inpartIofthisthesis. thereforequestion important most The promotewe can how was: adherence theseto improvement. achieve to trying of decades despite frequent, remains antibiotics of prescribing inappropriate and inadequate often is hygiene hand poor: notoriously is Unfortunately,guidelines. guidelineslocal these and to national adherence in invested been has lot a prevention, infection and prescribing antibiotic Toaid factors. these of new commission was to combat antibiotic resistance by combining efforts to tackle both thisof aim The (CIA). preventionAntibiotics Infection and on Commission the initiated In January 2014, the Amsterdam UMC, location VUmc, in Amsterdam, The Netherlands, antimicrobial stewardship andeffortstopromote infectioncontrol arepromote remarkably disconnected. to efforts coin; same the of sides two as they viewed rarely antibiotics), are for need the prevent will you infections, prevent you (if evident hygiene. hand as such measures control infection through prevention, in lies factor second the to key The stewardship. antimicrobial as known collectively are interventions These antibiotics. of use prudent promoting by resistance of development prevent to aim factor first and secondly, transmission, for example from person to person. Efforts directed at the Two factors greatly influence dissemination: firstly, the (unnecessary) use of antibiotics, resistance istherefore ofthe utmostimportance. become untreatable; preventing development and further dissemination of antibiotic eventually may infections everyday that is threat biggest The impossible. becomes surgery,chemotherapy) (e.g. medicine of part effectiveness large a the them, without antibiotics: on of hinges medicine not an modern is of It most that say medicine. to century overstatement twenty-first facing challenges biggest the named of been has one and growing is resistance antibiotic of problem The antibiotics. our of effects the withstand to bacteria of ability the describes resistance Antibiotic INFECTION CONTROL GUIDELINE ADHERENCEINANTIBIOTIC PRESCRIBINGAND 4,5 The importance of culture in hospital units became evident during evident became units hospital in culture of importance The 1 Although the connection between these two factors seems factors two these between connection the Although 2,3 the campaign and found great differences between hospital units in how much improvement had been achieved. In the qualitative investigation of safety culture that followed, we found that units with high levels of safety culture had improved their compliance, while units with lower levels of safety culture had not (chapter 2). This suggests that strengthening safety culture before implementing interventions (for example through team building exercises) could aid in achieving the behaviour change that is needed for improved guideline adherence.
Although guidelines are meant to support healthcare workers’ decision-making, they can be perceived as a way of ‘being told what to do’, which can make them counterproductive. A second important factor in achieving behaviour change is therefore involving stakeholders to prevent this sense of being ordered around. Structured group processes such as participatory action research, nominal group technique, and root cause analysis can be used to generate ideas, reach consensus, and engage group members in problem solving. 6,7 In another CIA project, we applied this approach to promote adherence to hospital dress code. Identifying causes for non-compliance and involving all stakeholders in the development of interventions to target these causes, led to improved adherence (chapter 3). These results strengthen previous findings that have shown that involving members of the target audience and addressing their barriers is essential in order to achieve behaviour change and improve guideline adherence.8
A third possibly useful method to achieve behaviour change is nudging: a friendly push to encourage desired behaviour. When healthcare workers seldom encounter clear problems of infections caused by antibiotic-resistant bacteria, they will consider the odds of transmission negligible, and this will greatly reduce their willingness to 10 adhere to guidelines. This is caused by so-called ‘heuristics’. Heuristics are defined as decisional short-cuts which can be useful, as they help us to quickly make judgements or decisions. However, when heuristics lead to cognitive biases, they may confound our judgement and thus influence our behaviour, which can lead to non-compliance. Nudges can address heuristics and cognitive biases and thus encourage certain behaviour. This was previously shown for influenza vaccination among healthcare workers: nudges specifically designed to target heuristics regarding vaccination were able to increase vaccine uptake. 9 In addition, nudges displayed as posters in general practitioners’ offices reduced unnecessary antibiotic prescriptions. 10 A systematic review of the literature provided us with several cognitive biases that can play a role in non-compliance with hand hygiene. In a controlled before-after trial, we showed that nudges, based on these cognitive biases and displayed as posters, can increase the use of alcohol-based hand rub when shown next to dispensers (chapter 4). 149 150 Chapter 10 ihr n eiet wt mr atnmu motivation autonomous more with residents in higher we found that participation in non-obligatory e-learning on antibiotic prescribing was hospitals), teaching two centres, medical university (two hospitals four of residents among study cohort a In duties. clinical demanding) (often with learning combine to need residents as e-learning, postgraduate to more individually.even applies This performedand non-obligatory usually is it as motivation, of lot requiresa E-learning However, a common downfall in non-obligatory e-learning is suboptimal participation. practice. clinical mimics that situation a in behaviour impact can and impact, long-term have versus 86%) and higher scores. This means that e-learning during a limited period can (97% percentages pass higher later,with months six examinations prescribing their students year an fourth- temporary,for implemented a course as non-compulsory antibiotics on module e-learning we which in students, medical VUmc among study in intervention effectiveness its on known is changing long-term little prescribing behaviour. used, increasingly is e-learning Although PART II–E-learning focus one-learningasaneducationaltool. addresses education of medical students and junior doctors on these subjects, with a insight is needed into its merits and into ways to maximize its effect. Part II therefore E-learning appears to be a valuable method, but to fully benefit from e-learning, more Education aimed at guideline adherence in busy daily practice therefore seems needed. knowledge and of clinical lack skills a such report as frequently prescribing doctors in medication, junior particularly time, antibiotics. same addressed the At measures. prevention seldom infection with are comply to how taught they nor interventions, Strangely, stewardship antimicrobial patients. with interactions very have frequent they as control, infection in role of key majority a play the and for prescriptions antibiotic responsible are doctors junior hospitals, Dutch In resistance. to attempting change behaviour than later on. This also applies to educating junior doctors on effective antibiotic more considered is start the from behaviour certain teaching education: in useful also is approach cure’ to than prevent to ‘better The EDUCATING JUNIORDOCTORS change strategies andthuspromote guidelineadherence. thereforecould easy,provideNudging an behavioursupport measureto inexpensive (chapter 5) (chapter . Students in the intervention group performed better in better performed group intervention the in Students . 13-15 We performed a prospective controlled catr 6) (chapter Autonomous . 11,12 motivation is described as motivation that originates from an interest in the subject or an understanding of its importance, as opposed to controlled motivation, which comes from rewards (such as credits). 16 Studies have shown that autonomous motivation is associated with higher study effort in medical students, 17 higher achievements in residents,18 and more increased participation in continuing education among pharmacists.19 This means that interventions to increase autonomous motivation could improve e-learning participation. Face-to-face education to explain the importance of the subject preceding e-learning, could enhance autonomous motivation and thus optimize e-learning participation.
Two other important aspects of educating junior doctors are of note. Firstly, timing. In VUmc, we interviewed residents from several specialties and found that junior doctors experience a hectic first few months, during which they are not receptive to (e-)learning. Secondly, while e-learning obviously aims to educate, we ultimately want doctors to put this knowledge into practice, a process that also requires behaviour change. We found that ‘nudging’, ‘creating a social standard’, formulating an ‘implementation intention’ and ‘public commitment’ are behavioural interventions that are easily incorporated in an e-learning module and are all acceptable to junior doctors (chapter 7). Determining the most opportune moment for e-learning and combining a module with behavioural interventions seems promising to improve junior doctors’ antibiotic prescribing and adherence to infection control guidelines.
DESIGNING GUIDELINES
One important question remains: if we aim to promote guideline adherence to 10 prevent further dissemination of antimicrobial resistance, how well are the guidelines themselves designed to do that? In part III, we investigated this for two common guidelines on antibiotic prescribing and infection control.
PART III – Antibiotic stewardship and infection control in guidelines Guidelines for antibiotic prescribing provide recommendations for empiric treatment of infections. Empiric means that at the time of prescribing, the causative organism and its susceptibility to antibiotics are not yet known, therefore treatment is based on epidemiology: the most common causative pathogens of this type of infection and their susceptibility to antibiotics.20 Guidelines for empiric treatment are usually adjusted when resistance of the most likely pathogen reaches 10%. 21 This makes sense for ‘simple’ infections such as urinary tract infections: most are caused by Escherichia coli, therefore if E. coli’s resistance to the empiric therapy increases, this will affect most 151 152 Chapter 10 352 haematology patients, constituting 18977 catheter days. We found that in these in that found We days. catheter 18977 constituting patients, haematology 352 in episodes PICC 455 assessed study,we cohort multicentre a In antibiotics. for need this assumption, routine replacement of PICCs may prevent CLABSI and thus lower the time. indwelling longer non- with increases is infection of lines risk the central that i.e. of linear, colonization bacterial that proposed have (CLABSI). studies infection Previous bloodstream line-associated central with associated are PICCs lines, central other Unfortunately,like months. even or weeks for situ in remain may and access venous for areused (PICCs) centralcatheters peripherallyinserted patients, of bleeding, the question of prevention over cure is more complicated. In haematology replacement asof However,these devices time. has several of downsides, such periods as patient prevent discomfort longer and riskfor may place devices in are such they when of especially replacement infection, timely that think to common is It lines. intravenous and catheters urinary as such devices, prevention medical and using when treatment infections of the is making decision clinical in question important An ‘stewardship’-proof, asthisisoverlookedincurrent approaches. are guidelines whether on focus also therefore should prescribing antibiotic prudent promote to Efforts resistance. antibiotic of development further and events, adverse important in increase associated an with rates overtreatment high to lead may BSI, of account that this resistance only occurs in a very small proportion of patients suspected into taking without pathogens, likely most the of resistance on based therapy empiric better guide empiric treatment decisions. to needed are stratification risk improve to Efforts practice. common still is treatment before, out pointed been have pathogens single for percentages cut-off with issues the Although prescribed. were they to whom patients ten of out nine to eight as many as in superfluous deemed was therapy difficile of risk the increased significantly therapies) combination aminoglycosides that in these patients, the use of more broad-spectrum antibiotics (i.e. carbapenems or resistance of ‘dilution’ named we phenomenon manya are there group; diverse and negative. remain often cultures blood and pathogens, causative large possible a encompass BSI of suspected Patients 20%. reaching Gram-negatives among 3GC-resistance despite BSI, of suspected patients of that resistance to second-/third-generation cephalosporins (3GC) affected less than 2% retrospective cohort study, we investigated multicentre,a In (BSI). bloodstreaminfections as such agents, causative possible many with infections with dealing when problem a However,causes approachpatients. this neto ad ct kde ijr, epciey I adto, broad-spectrum addition, In respectively. injury, kidney acute and infection 24 However, until then, the practice of adapting 22,23 ˃4000 patients suspected of BSI. We found this approach to adaptation of empiric of adaptation to approach this (chapter 8) (chapter . We additionally found additionally We . 22 This causes This Clostridium 26-28 Under 25 patients, the cumulative risk of CLABSI increases slightly during the first 28 days, but does not increase with longer indwelling time thereafter. These findings suggest that routinely replacing PICCs before 28 days, e.g. after 2 weeks, would prolong the period of increased risk, while routine replacement thereafter would not aid in preventing PICC-associated infections in this population (chapter 9).
FUTURE DIRECTIONS
The challenge of antibiotic resistance has many facets, including important behavioural, political and financial aspects. The importance of the latter is painfully portrayed by what has been named the discovery void, an ongoing period since 1987, during which no (genuinely) new classes of antibiotics have been developed. To pharmaceutical companies, development of new antibiotics is not of interest: antibiotics are used for a very limited time (typically a few days to a few weeks) and physicians are encouraged to use as little of them as possible, so expected revenues are too low. This means that other incentives (for example from governments) are needed to secure investments in research and development, but these are slow to take form.29 Therefore, until then, we must preserve what is left of our precious antimicrobial arsenal; prescribing doctors carry the heaviest responsibility in securing their future effectiveness.
Preserving the efficacy of antibiotics forms the cornerstone of antibiotic stewardship programs, which encompass efforts to ensure prudent use. However, as mentioned before, most of these programs disregard a very clear aspect of the antimicrobial resistance challenge. The saying ‘an ounce of prevention is worth a pound of cure’ most 10 certainly goes for antibiotic resistance: prevent infections, and there will be less need for antibiotics. This has been an important factor underlying this thesis; much of the work was founded on the notion that antibiotic stewardship and infection control are intertwined themes that need a combined approach and can benefit from approaches based on the same concepts. The work presented in this thesis shows that involving the target audience and addressing their barriers is essential to creating successful interventions and consequently achieving behaviour change. This not only applies to the design of new interventions, but perhaps even more so to the implementation of interventions that were developed elsewhere, as these are typically less successful. 30 This failure to implement previously successful interventions is often attributed to the ‘not invented here syndrome’. This syndrome causes a negative attitude towards products or knowledge developed in other organizations or disciplines, which leads to its suboptimal utilization or even rejection. Instead of fighting this syndrome, 153 154 Chapter 10 t ae cosn a rfre oto ese, ihu tkn aa ls fortunate less away taking without easier, option preferred a choosing makes it non-compliance. to leading thus low, also are to believe that the chances of transmitting an infection through lack of hand hygiene prevalence of healthcare-associated infections is low, healthcare workers are inclined a diagnosis of that same rare disease much more likely. Conversely, this means that if consider will they patient, next their in disease, rare a with patient a diagnosed just occur.to it consider we likely more the recall, to is event an easier the it: recall can we which with ease the the by event assess an of probability we how describes which heuristic’, ‘availability the is example striking role. a play to proposed been have heuristics underlying and biases cognitive our judgement and thus influence our behaviour. In medical decision making, several or decisions. as decisional shortcuts which can be useful, as they help us quickly make judgements defined be can heuristics Kahneman, Tverskyand by detail in Described ‘heuristics’. non-compliance. someone’s underlie that biases cognitive addressing by behaviour influence also can nudges that suggested behaviour. prescribing physician influencing in successful proved nudges of kinds various which instudies, few a addressedrecently in been only has healthcareworkers of Nudging the healthierchoice. product’s favourable acharacteristics, such as ‘low-fat,’ highlight can nudge consumers towardsthat labels descriptive choices: food healthy and cessation smoking as want, or need often criticised as a mere way to trick consumers into buying things they do not really Although buys. impulse make to us causes that ‘architecture’ or layout a check-out: supermarket the near positioned when look can products attractive how know all a term coined surroundingsSunstein, and Thaler by originally ‘choice architecture’, our that means of This layout the we choose. that how fact influences the on relies nudging of concept The that cansupportother, perhapsmore impactfulones. nudging, as such interventions, small seemingly for look to pays it that shown have we interventions, single successful highly for look to tendency scientific our despite addition, In adherence. ultimately and support generate to tool powerful a be can own, their them make to them shape workers healthcare having and interventions else. someone by constructed were but identical, arethat items IKEA-effectfor creationsthan own our greaterappreciationfor have to us causes The IKEA-effect. the as known counterpart, positive its utilize can we 10,37-39 40 However, when heuristics lead to cognitive biases, they can confound 34 Although the exact mechanism has not been clarified, it has been has it clarified, been not has mechanism exact the Although ugn i as wdl ue t siuae elh bhvor such behaviour, healthy stimulate to used widely also is nudging 35,36 33 makes it possible to impact decision-making. Wedecision-making. impact to possible it makes 9 ontv bae ae fe cue by caused often are biases Cognitive 43 vtl etr o ndig s that is nudging of feature vital A 31,32 40 For example, if physicians have physicians if example, For aig xsig udlns or guidelines existing Taking 41,42 A alternatives. Nudging thus preserves professional autonomy, which is integral to improving guideline adherence.8 It is a strategy not yet commonly used in health care (perhaps also driven by the, not invented here, syndrome), but with enough promising potential to warrant further research.
As virtually all doctors are allowed to prescribe antibiotics, regardless of specialty, experience, or knowledge, it has to be made clear to all (aspiring) doctors that antibiotic resistance is a complex problem, that requires their attention. Unfortunately, education of future prescribers is often overlooked in antibiotic stewardship programs. Prudent use of antibiotics is an integral part of rational medical decision making, and should be approached as such from the beginning of medical training. This includes education on how to handle guidelines: a vital but sometimes neglected aspect of guideline adherence is reasoned deviation from them, which we should actively teach future and junior doctors. An undergraduate to postgraduate continuum that incorporates blended learning (a combination of face-to-face learning and e-learning), explains their responsibility towards preservation of antibiotics, 44 and teaches them how to handle guidelines, is needed to achieve responsible prescribing. To fully benefit from blended learning, future studies should focus on the remaining question whether face-to-face education can enhance participation in e-learning and can thus improve appropriate prescribing.
Rising antibiotic resistance also challenges us when we develop guidelines for empiric antibiotic treatment. Empiric therapy comprises a calculated risk: the risk of empiric undertreatment versus the risk of adverse events due to empiric overtreatment. When considering adaptation of empiric guidelines, we are confronted with an increasingly delicate balance between the two. Although the effects of (unnecessary) treatment 10 with broader-spectrum antibiotics on the development of antibiotic resistance are well- known,45,46 fear of too narrow empiric treatment usually dominates, and side effects in individual patients are often brushed aside. Our study showed that resistance rates of a subgroup of possible causative pathogens have little impact on the risk of undertreatment, which means that this resistance does not translate well to the individual patient. Efforts to improve risk stratification24 and decrease time to susceptibility results are therefore much needed to guide future empiric treatment decisions.
155 156 Chapter 10 implementation, to assess the effect on those for whom it matters most: our patients. prescriptions antibiotic of appropriateness reviewing by trial randomized cluster wedge, stepped IKEA-effect. We would propose to apply this combined intervention in a multicentre, the of use full make to paramount is programs stewardship local with collaboration close therefore success; their to integral is development their to approach the but themselves, interventions the importantly,not Most importance. the of explanation reinforce its effect and nudge them towards the desired behaviour, practice, daily in skills these several behavioural interventions, such as explicitly formulating a commitment to applywith module educational this combine to interesting be would It barriers. perceived overcoming on focuses and needs, doctors‘ junior at aimed quizzes interactive and lectures,web vignettes, case of consists It experts. educational and behavioural and among junior doctors, with input from medical specialists, infectious disease experts, control, to develop an e-learning module. This module was pilot-tested and evaluated infection and prescribing antibiotic on education regarding doctors junior of needs We previously applied the lessons learned from be thetarget populationforfurtherresearch. trial. As junior doctors are often overlooked in stewardship interventions, they should randomized a during practice clinical in control infection and prescribing antibiotic on effect its assess and thesis, this of findings the combine to be would resistance complex requires antibiotic prevention of dissemination further prevent to its efforts in step next The and interventions. problem complex a is resistance Antibiotic 48 and the occurrence of hospital-acquired infections before and after and before infections hospital-acquired of occurrence the and 47 cues that remind participants of their commitment to commitment their of participants remind that cues chapter 7 , in which we assessed the 10 and face-to-face REFERENCES
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159 The journey is the thing - Homer, The Odyssey CHAPTER 11 Publications Dankwoord Acknowledgements Biografie Biography
11 162 Chapter 11 Nederlands TijdschriftvoorGeneeskunde. 2014Aug18. MG Caris Metab. 2015Feb. dysphoria. gender with adolescents in treatment hormone sex cross- and treatment analog hormone gonadotropin-releasing following adulthood D, Klink of PCRintheabsenceaserologic reaction. MG Caris Study onHandHygiene. CMJE. Grauls Caris MG Compliance WithHospitalDress Code. CMJE. Grauls Dekker M, 2018 Jan. type 1 diabetes and impaired awareness of hypoglycemia. hypoglycemia revisited; a secondary analysis from an intervention trial in patients with CAJ, Beers van 2018 Apr. CMJE. Vandenbroucke-Grauls MG Caris after sixmonths. E-learning of effect the students: medical in skills prescribing antibiotic Improving JJ, Sikkens prospective a participation: in cohort study. motivation autonomous of role the – prescribing MG Caris PUBLICATIONS Caris M Caris , Kamphuis PGA, Dekker M, de Bruijne MC, van Agtmael MA, Vandenbroucke- , Peerbooms PG, van Lieshout L, Veenstra J. Amebic liver abscess; the rolethe abscess; Veenstraliver L, J.Amebic Lieshout van PeerboomsPG, , Skes J Ksra R, a Atal A Elann o antibiotic on E-learning MA. Agtmael van RA, Kusurkar JJ, Sikkens , Caris MG I ht ot Atboiaeitni voset eadlucs niet. behandelsucces voorspelt Antibioticaresistentie kort: het In . Lbshge A Dke M vn gme M, rmr MHH, Kramer MA, Agtmael van M, Dekker HA, Labuschagne , ai MG Caris J Antimicrob Chemother. 2018Aug. Effectiveness of a Behavioral Approach to Improve Healthcare Worker Healthcare Improve to Approach Behavioral a of Effectiveness Patient Safety Culture and the Ability to Improve: A Proof of Concept of Proof A Improve: to Ability the and Culture Safety Patient Caris MG Caris , Heijboer A, van Trotsenburg M, Rotteveel J. Bone mass in young in mass Bone J. Rotteveel TrotsenburgM, van A, Heijboer , J Antimicrob Chemother. 2018Aug. , van Gunsteren AM, van Mansfeld R, Lucas C, Vandenbroucke- Shte , rmr H, ihla J vn gme MA. Agtmael van J, Tichelaar MHH, Kramer T, Schutte , Infect Control HospEpidemiol.2017Nov. , DeVries JH, Serné EH. The relation between HbA1c and HbA1c between relation The EH. Serné JH, DeVries , ugn t Ipoe ad Hygiene. Hand Improve to Nudging Infect Control HospEpidemiol.2017Dec. Travel Med InfectDis.2015Sep-Oct. J Diabetes Complications. Ci Endocrinol Clin J Hs Infect. Hosp J DANKWOORD
Een goed woord van dank is een zegening voor elk proefschrift - De Speld
Vele mensen hebben op hun manier, misschien zelfs zonder het te weten, bijgedragen aan het werk dat u nu in uw handen heeft. Ik hoop dat ik mijn waardering hiervoor eerder al heb laten blijken, maar zet deze hier graag zwart op wit.
Om te beginnen dank aan alle verpleegkundigen, arts-assistenten, specialisten, coassistenten, studenten geneeskunde én patiënten die de verschillende studies mogelijk hebben gemaakt. Dank ook aan alle medewerkers van VUmc met wie ik vanuit het A-team en I-team heb mogen samenwerken, in het bijzonder de afdeling medische microbiologie.
Dan mijn promotieteam. In 2014 begon ik als pas afgestudeerd arts bij de nieuw opgerichte Commissie Infectiepreventie- en Antibioticabeleid in VUmc. Samen met Jonne in het A-team en met de afdeling Infectiepreventie in het I-team, mocht ik me storten op grote veranderingen in VUmc. Veel moest worden uitgezocht, opgezet en uitgeprobeerd, en gaandeweg ontstonden er plannen voor onderzoek. Al vroeg gaven jullie mij de steun en het vertrouwen om zelfstandig aan de slag te gaan. Er was altijd veel ruimte voor ideeën, waardoor ik als onderzoeker snel heb kunnen opgroeien. Daar ben ik erg dankbaar voor.
Michiel, van begin af aan liet je mij mijn meeste bijdehante zelf zijn. De woensdagochtenden met Jonne waren altijd inspirerend, op jouw kamer mocht alles gezegd worden. Als promovendus was het bij jou nooit moeilijk te raden of ik op het 11 goede spoor zat; sprankelende ogen en een stem met uitroeptekens of een frons met een vertwijfelde vraag, met beiden kon ik verder. Met de deur in huis vallen en ‘het vangen in een plaatje’, daar zal ik altijd de vruchten van blijven plukken. Leuk om te merken dat we nog niet zijn uitgedacht.
Christina, ik heb het altijd als een voorrecht beschouwd om bij jou te mogen promoveren. Je enthousiasme voor onderzoek, je vermogen om gelijktijdig de kleinste details én de grote lijnen in het oog te houden, maar ook hoe je altijd geduldig klaarstaat om advies te geven, zijn voor mijn een inspiratie. Ik moet de eerste zin die niet beter wordt van jouw gesleutel nog tegenkomen. Dank dat ik altijd met mijn vragen bij je terecht kon (en kan), dank voor de fijne gesprekken en voor je tijd en aandacht.
163 164 Chapter 11 ongelofelijk knap hoe jij het allemaal doet. Fijn dat we zowel binnen als buiten het buiten als binnen zowel we dat Fijn doet. allemaal het het jij vind hoe ik knap agenda(‘s), ongelofelijk jouw onder bezweken zijn jij allang ben zou Wat Menigeen worden. beest. gezien een mag het maar gezegd, vaker wel dit ik heb Misschien Angels. Agtmaels van 3 nummer lid Nick, denken. vol mogen te je veel met whiteboards nog toekomst de in hoop Ik bijgedragen. aan enorm daar heeft gelaten, werd Jonne, ‘de eeuwige vragensteller’, als kamergenoot geen enkel onderwerp ongemoeid met Dat verlopen. laten hebt overgang die je makkelijk hoe gevonden bijzonder altijd het heb ik collega; als blijven mocht daarna ik dat feest een was Het proefschriften. onze allebei in gekregen heeft plek een die werd studie prachtige een het dat is leuk Extra geleerd! van zoveel ik bij heb ik: Daar doen. wist stage wetenschappelijke presentaties mijn ik je wil van jou een van zien het Na meegemaakt. onderzoeker als ontwikkeling mijn jij heb ander geen als Jonne, VUmc. in collega-onderzoekers Mijn een inspiratie. iswerken en denken van farmacotherapie.manier sectie Jullie de van uitmaken mocht deeldocent als anderen,ik en dat agendagoochelaar) dank (de Lieke David, Tim, Jelle, jullie hulp,envoorgeduldmetkritischebegeleider. voor dank veel Dorien, en Casper Roos, Lisa, Pim, Vincent, Heleen, Jan, Henk blijven. te pad wetenschappelijke het op om geholpen mij hebben studenten Verschillende onze samenwerking. van voortzetting een Op enthousiasme. aanstekelijke en doorzettingsvermogen jouw De ‘dat doen we toch gewoon?’-mentaliteit zit in jouw DNA. Enorm respect heb ik voor Mireille, vlak na elkaar begonnen wij bij VUmc en dat heeft tot prachtige dingen geleid. Ik hebveelvanjulliegeleerd. Dankvoorjulliebijdragen aanmijnproefschrift. als ik (niet gehinderd door enige kennis) weer eens wat wilde opzetten of uitproberen. Paul en Henny. Veel dank dat jullie mij toelieten in jullie domein, me steeds aanhoorden Collega’s van de afdeling infectiepreventie. Mireille, Suzanne, Liz, Annie, Rosa, en eerder inspirerende de voor dank gesprekken. VUmc, buiten en binnen ontmoeten, mogen heb ik die arts-microbiologen en Infectiologen waardevol. zeer waren ideeën en opmerkingen scherpe jullie lezers, kritische andere en Coauteurs besteed. hebben proefschrift mijn Vervolgens dank aan de leden van de leescommissie voor de tijd en aandacht die zij aan te wetendatjedeuraltijdopenstond. om fijn heel was het schouderklopjes, en woorden bemoedigende je voor dank Mark, ziekenhuis fijn kunnen kletsen. Ik ben heel trots op ons gezamenlijke stuk. Stieneke, mijn eerste 2 jaar was 3A74 ons veilige hok. Dank voor je eerlijke gesprekken, koffie en verjaardags- en sinterklaasvieringen. In mijn laatste jaar mocht ook ik mij een 4A45’er noemen; Nadia, Jeske en Rishi, het was een eer de kamer met jullie te delen. Jennifer, zo leuk dat we elkaar buiten het ziekenhuis blijven tegen komen. Liselotte, Anna, Erik, Louise, Edmee, Annelies, Lennart, Marcel en Mark, een wandeling over de gang bracht altijd iets moois, dank daarvoor!
Mijn paranimfen, Koen en Wessel. Alle drie hebben we promotieonderzoek gedaan in VUmc en alledrie zijn we gestart met de opleiding tot internist. Maar daar houdt de vergelijking eigenlijk wel op. Dat we zo anders zijn, vind ik geweldig. Lieve Koen, met jou in een ruimte voel ik me altijd gesteund. Een (zware) wenkbrauw, een blik, een gemompeld grapje. Ik vind het mooi om te zien hoe jij balanceert tussen nieuw en oud. Als geen ander hecht je aan traditie, terwijl je tegelijkertijd nieuwe dingen omarmt. Lieve Wessel, als kamergenoten praatten we de dagen vol, zelden over wetenschap. De muur met foto’s groeide met ons mee. Je bezit de gave om gesprekken met open blik én armen aan te gaan, maar ook te weten wanneer het tijd is voor iets anders. Lieve boys, bergen beklimmen, letterlijk en figuurlijk, doe ik dolgraag met jullie. Wat ben ik blij en trots dat jullie ook vandaag aan mijn zijde staan.
Dank aan mijn (schoon)familie voor jullie niet-aflatende interesse in mijn onderzoek (detail voor de Nanninga’s: hoofdstuk 8 en 10 kwamen voor een groot deel tot stand in inspirerend LCV). Aan alle vier mijn schoonouders in het bijzonder, dank dat ik al zo lang bij jullie mag horen.
Aan alle lieve vrienden die ik rijk ben. Dank voor jullie scherpe blikken op het leven, 11 en jullie eindeloze geduld met mijn flauwe grappen. Zo fijn dat er linksvoor altijd een paal is om naartoe te rennen en dat wij CGU’ers twintig jaar (!) later nog steeds aan elkaar vragen hoe we het maken.
Mijn lieve ouders, Jan en Ineke. Papa en mama, het is gelukt! Hoewel ik weet dat jullie er nooit aan hebben getwijfeld dat deze dag zou komen, voel ik hoe jullie vandaag met mij uitademen. Dank voor jullie steun en oneindige vertrouwen.
Dan mijn broer, Koen. Een groot deel van dit proefschrift schreef ik zittend tegenover jou, soms als onderdeel van de FU-triangle, soms als God in Frankrijk. Ik ben ongelofelijk trots dat jij mijn broer bent, en dat we dit stukje van onze verder zo verschillende werklevens konden delen. Wat is het fijn om nog altijd samen op te mogen groeien. 165 166 Chapter 11 ben bijjou. ik wie voor en bent, jij wie voor Dankjewel jij! ben dat afleiding, leukste De halen. teop schouders mijn toe en geleerdaf me hebt jij beschermen, te mezelf tegen dan en nu zo me om staat in je ben ander geen Als gekomen. was nooit wel misschien jou zonder er het dat ik denk eigenlijk maar maken, vaak we die grap Een geweest! af eerder veel proefschrift dit was jou… Steef,vrouw.zonder Lieve mijn slot, tot En 11
167 168 Chapter 11 de geneeskunde. zij van hoopt pijlers drie deze van toekomst combinatie een met houden de blijven te bezig ook in dan zich element; haar in Martine is wetenschap en onderwijs werkzaamheden, klinische van driehoek prof.de Y.F.C.dr.In (opleiders en Smets). Y.dr.Smulders Amsterdam in OLVG het in internist tot opleiding de met begon Zaans Medisch Centrum in het Zaandam (opleider dr.in A. van Tellingen),geneeskunde waarna zij in mei 2018 interne de bij ANIOS als zij startte 2017 september In VUmc). Biostatistiek, en Epidemiologie (afdeling EpidM bij behalen epidemiologie klinische VUmc en behaalde haar Basiskwalificatie Onderwijs (BKO). In 2019 zal zij haar master toegejuicht door haar ouders), werkte zij als docent bij de sectie farmacotherapie van (stilletjes onderwijs voor interesse een Martine ontwikkelde commissie de voor werk haar Tijdens teruglezen. proefschrift dit in u kunt projecten deze van sommige van uitkomsten de stimuleren; te antibiotica van gebruik zorgvuldig als infectiepreventie zowel om projecten verschillende zij coördineerde en ontwikkelde infectiepreventie afdeling de en Sikkens Jonne collega met Samen Agtmael. van Michiel dr.prof. en Antibioticabeleid in VUmc, onder leiding van prof. dr. Christina Vandenbroucke-Grauls Martine een aanstelling binnen de nieuw opgerichte Commissie Infectiepreventie- en kreeg proefschrift), dit van 6 (hoofdstuk geneeskunde interne afdeling de bij stage interesse haar voor ontstond de Veenstra),infectieziekten. In Jan 2014, dr. na van het afronden supervisie van onder haar wetenschappelijke West, OLVG (nu Ziekenhuis een klinische stage in Butare, Rwanda en haar semiartsstage in het Sint Lucas Andreas Klink assisteerde in het Kennis- en Zorgcentrum voor Genderdysforie in VUmc. Tijdens BIOGRAFIE nees vo odrok te zj r Daniël dr. zij toen onderzoek, voor interesse laude 2014 in zij aan die centrum, medisch geneeskunde VU het opleiding de met decentrale selectie na 2007 in begon en Amsterdam naar verhuisde Zij leerde. druivenplukken het van kunst de andere onder zij waar Australië, door backpack met jaar half een zij trokUtrecht Gymnasium Christelijk het op eindexamen haar Na onderwijs. voortgezet het in docent beiden jongerebroer Koen Ineke,en Jan ouders hun en haar met opgroeide februari zij waar Utrecht, 27 in 1987 op geboren werd Caris Martine afrondde. Als student ontwikkelde zij een zij ontwikkelde student Als afrondde. cum
BIOGRAPHY
Martine Caris was born on 27 February 1987 in Utrecht, where she grew up with her younger brother Koen and their parents, both of whom where secondary school teachers. After graduating from the Christelijk Gymnasium Utrecht, she spent six months backpacking (and picking grapes) in Australia. She then moved to Amsterdam, and in 2007, was accepted into medical school via ‘decentral selection’ at the VU university medical center, from which she graduated cum laude in 2014. Her interest in research started as a student, when she assisted dr. Daniel Klink at the Center of Expertise on Gender Dysphoria in VUmc. A clinical internship in Butare, Rwanda and her final clerkship in OLVG West (formerly Sint Lucas Andreas Ziekenhuis, supervised by dr. Jan Veenstra) spiked her interest in infectious diseases. In 2014, after finishing her scientific internship at the department of internal medicine (chapter 6 ofthis thesis), she was appointed for the newly founded Commission on Infection prevention and Antibiotics in VUmc, under the guidance of prof. dr. Christina Vandenbroucke- Grauls and prof. dr. Michiel van Agtmael. Together with colleague Jonne Sikkens and the department of Infection control, she developed and coordinated several projects to promote both infection control and prudent use of antibiotics , some of which are part of this thesis. While working for the commission, Martine developed an interest in teaching (which her parents silently applauded), joined the pharmacotherapy section of the department of internal medicine as a teacher and obtained her Basic Teaching Qualification (BKO). In 2019, she will obtain a master’s degree in clinical epidemiology from EpidM (department of Epidemiology and Biostatistics, VUmc).
In September 2017, Martine started working at the department of Internal medicine of the Zaans Medisch Centrum in Zaandam (supervisor dr. A. van Tellingen). In May 11 2018, she started her residency in Internal medicine at OLVG West in Amsterdam (supervisors prof. dr. Y. Smulders and dr. Y.F.C. Smets). Martine is at her best balancing clinical work, medical education and research; in the future, she hopes to continue combining these three pillars of medicine.
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UITNODIGING
Voor het bijwonen van de openbare verdediging van het proefschrift:
IMAGINE
IMproving Adherence to Guidelines in Infectious diseases through Nudging and Education
Op donderdag 19 september 2019 om 13.45 in de aula van de Vrije Universiteit, de Boelelaan 1105, Amsterdam
Aansluitend bent u van harte welkom op de receptie ter plaatse
Martine Caris Lutmastraat 77-3 1073 GP Amsterdam [email protected] 06-21907756
Paranimfen Koen van Beers [email protected] 06-11241753
Wessel Fuijkschot [email protected] 06-40102292
Martine Caris diseases through IMAGINE Guidelines in Infectious IMproving Adherence to Adherence IMproving Nudging and Education Martine Caris diseases through Nudging and Education Nudging diseases through IMAGINE IMproving Adherence to Guidelines in Infectious in Infectious Guidelines to Adherence IMproving
IMproving Adherence to Guidelines in Infectious diseases through Nudging and Education Martine Caris