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Table 5 Representative positive, negative, and best practices responses for CFIR inner setting domains for CRE guideline implementation

From: Evaluation of carbapenem-resistant Enterobacteriaceae (CRE) guideline implementation in the Veterans Affairs Medical Centers using the consolidated framework for implementation research

CFIR domains

Representative responses

Positive

Negative

Best practices

1. Available resources

Definition: Money, equipment, testing supplies, training, education, isolation space, staff time, IT support, and previous workarounds to facilitate guideline implementation are available

IT support and staffing:

(…) we have a CPRS [discharge] template. [CRE status] would be communicated in the template and the nurses [also] call the accepting facility and give a [verbal] report. [MPC]

Timely lab reporting:

The [CRE testing] cartridges last about 4-6 months, (…) and if I only get 3 [CRE cases] within those 6 months, then I have to throw the other 7 cartridges away. [By comparison, the University lab can provide] results in] …about 24 hours. [Laboratory]

Lab testing equipment and training:

[New lab equipment has to be purchased and time has to be allocated for staff to be trained and be proficient.] It’s hard to add new testing in the VA. [Laboratory]

Staffing:

[We] had a lot of [staff] turnover in infection control for a long time, and when you have less experienced with] less training, then that’s a challenge.

[Infection Control Staff]

We just don’t have the staff [to implement CRE screening] right now.

[MPC]

Educational materials/Staffing:

It would be nice to have [more educational] materials [and staff release time for CRE-related training]. I tried … to do an in-service every 30 minutes and [only] had 5 people that day. [MPC]

Isolation beds:

[Our] spinal cord [unit] is a problem because they [only] have four bed room[s] [individual isolation rooms are not available]. That’s an infection control issue if someone is [CRE] positive. [MPC]

IT support:

The handoff communication is verbal and the transfer note doesn’t [routinely address the patient’s] isolation status. When I call the new unit, [unless] they check their Theradoc ® … they won’t know. [MPC]

Staff training workaround:

[In addition to] unit-based training, [we] developed poster boards [for] the Infection Control week. After [the] initial training, physicians were still ignoring and bypassing order sets. [So] posters [were hung] in meeting rooms and any rooms where physicians did their documentations. They finally are getting numbers that are representative. [Infectious Disease Chief]

Training and materials:

The acute care people do not think it’s important to have a full class. … I do a train-the-trainer session [now]. [MPC]

Lab reporting:

But since [our lab] system was updated with the new isolates and packages, we are now able to select the CRE organism. We are doing active surveillance and Infection Control developed a list of high-risk patients and recommendations for screening from the guidelines. [Laboratory]

If a [CRE+] patient is… flagged from a previous encounter, …they are automatically put in isolation on admission [based on] the Theradoc® documentation. [Laboratory]

2. Networks and communication

Definition: Local infrastructure for national guideline or training material dissemination (e.g., CRE-related conference calls to train staff).

[Our] electronic communication includes… a daily print out… an email group … [for] asking questions and vice versa … [and] hard copies of [overnight] test results. There may [also] be a phone call or a voicemail. It’s [a] multi-prong approach. … We have pamphlets online that they [staff] can print if we [Infection Control] aren’t around. We try to coach them to be self-sufficient. [Infection Control Nurse]

[Guideline information is disseminated] through [the] MDRO group, … front office … [and] the VISN. [Staff] attend [the] Antimicrobial Stewardship Program interdisciplinary committee meeting, …staff meetings, … [and receive] email from the IP doctor. [MPC]

There is a lag in the policy being implemented once published. [I] didn’t get [timely MPC-level] access to the [MDR Office] communications, emails, and calls. [Infection Control Manager]

There were a lot of delays here, … outdated policies and possibly didn’t rise to the top as priorities], [causing] a lag in communications… [So, guideline] issues haven’t been brought up [to VAMC and VISN] Infection Control yet. [Infection Control Manager]

I also created an [CP-CRE] algorithm … [that] informed everyone …who to test, what to do, and when to contact Infectious Disease. There is also a binder on every unit where everything sits. [MPC]

I go to [the units] and make sure they have all signs up, … [and that] they have … [participated in a CRE] in-service. I asked them to educate the patient … or I’ll do it with them if they aren’t comfortable. I also talk to the attending and resident physician as well. Some don’t understand the need for isolation, so it’s important we speak to everyone. [MPC]

3. Leadership engagement

Definition: Commitment, involvement and accountability of local leaders and managers with the guideline implementation.

[If we tell leadership what’s needed], they’ll say okay and get it for us. If we started seeing more CREs, and we need [new testing equipment], they’ll find the money to support it. [Laboratory]

Laboratory [leadership handles all] equipment needs … and any new assays. [Infection Control Staff]

[Based on previous experience,] we go to [leadership] saying we need … [lab equipment] and they’ll say okay and get it for us. [Laboratory]

[Leadership] allowed us to do a CPRS flag and … to send out confirmation testing and … set up send out protocols. However, it takes a long time to get this much done. [MPC]

[Our] Medical Director is also very involved in Infection Control and Infectious Disease… [and] works with [us] on projects that arise. [MPC]

We’ve implemented a great [computer] tool … for screening admissions for [CRE] risk factors and [are] implementing … swabbing for those with risk factors (e.g., international travel, organ transplant recipients). [MPC]

4. Culture

Definition: Infection Control policies already implemented locally or in anticipation of new MDROs.

I think our facility takes a very strong stance on minimizing exposure. In general, the culture here is very aware of infect[ious] agents and how to prevent spread. The facility [has only private rooms, which] helps. [Laboratory]

We don’t have a big problem with it [CRE] yet. It’s the new emerging pathogen and we are giving it a lot more press. I think the [staff has] … a good attitude. [MPC]

Some people do or don’t see or follow [existing MDRO practices, like] hand hygiene and PPE appropriately, all the time for a variety of reason[s]. [MPC]

[Providers] think it’s ridiculous, that we require contact precautions. [MPC]

[At the monthly Infection Control meeting], we always make sure to talk about [CRE] and what new processes we need to implement or … improve. [Laboratory]

Every new [lab] person has to rotate through microbiology. [Laboratory]

We’ve done an excellent job with MDROs at the facility, people are very cooperative and enthusiastic. [Our] MRSA [rate] is dropping rapidly. People are really working hard …with Infection Control … to clean rooms, …come to the Infection Control meetings, and there [are] always questions. The [Infectious Disease] Chief does a lunch and learn… every month. He answers any questions about infection control. [Laboratory]