1095 — Evaluating implementation of guidelines to prevent Carbapenem-Resistant Enterobacterales in VA medical centers

Lead/Presenter: Charlesnika Evans,  COIN - Hines
All Authors: Evans CT (VA Center of Innovation for Complex Chronic Healthcare, Hines, IL), Fitzpatrick M (VA Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL) Goedken CC (Iowa City VA Health Care System (CADRE), Iowa City, Iowa) Guihan M (VA Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL) Wilson G (VA Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL) Jones M (VA Salt Lake City Healthcare System (IDEAS), Salt Lake City, Utah) Pfeiffer C (Portland VA Health Care System, Portland, Oregon) Perencevich EN (Iowa City VA Health Care System (CADRE), Iowa City, Iowa) Rubin M (VA Salt Lake City Healthcare System (IDEAS), Salt Lake City, Utah) Evans M (VA Multidrug Resistant Program Office, Lexington VA Medical Center, Lexington, Kentucky) (Suda KJ) Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania

Objectives:
Infections caused by highly-resistant carbapenem-resistant Enterobacterales (CRE) and carbapenemase-producing (CP)-CRE, a sub-set of CRE, are difficult to treat, resulting in high mortality. To reduce the spread of these organisms in healthcare settings, the VA disseminated guidelines in 2015 and a Directive in 2017 for control of CRE/CP-CRE in VA Medical Centers (VAMCs) focused on laboratory testing, prevention, and management. The QUERI CARRIAGE Program evaluated implementation of these guidelines in collaboration with the VA Multi-Drug-Resistant Organisms (MDRO) Program office.

Methods:
A mixed-methods learning evaluation using the Consolidated Framework for Implementation Research (CFIR) was used to provide rapid implementation feedback to operations. To assess concordance with recommendations included in the VA guidelines/directive, surveys were conducted with laboratory/microbiology supervisors (N = 129) (6/26/2017-11/2/2017) and MDRO prevention coordinators (MPCs) (N = 134) (2/21/2018-4/30/2018). To evaluate implementation, 43 semi-structured interviews were conducted with MPCs, infection preventionists, laboratorians, and physicians (10/2017-8/2018). CDW data was used to assess change in hospital-onset (HO)-CRE over time (2013-2018) using an interrupted time series (ITS) design.

Results:
Most VA laboratories (91.6%) were following guidelines for CRE identification (response rate = 93.0%), but only 55.0% were using guideline-recommended diagnostics to confirm CP-CRE. High-complexity facilities were more likely to report adequate resources, use recommended diagnostics, and reported higher levels of knowledge and comfort implementing the guidelines versus lower complexity facilities. Nearly all MPCs (97%) reported using the VA guidelines (response rate = 58.9%); half (56.8%) reported they were ‘fully’ implemented at their facility; most frequent reason for not being fully implemented was no screening for CRE. Few (20.9%) reported screening for CRE colonization or receiving communication about CRE status on patient transfer from non-VA facilities (22.2%) or VA facilities (42.0%). Across laboratory and MPC respondents, staffing, training, and resources were cited as barriers to guideline implementation. Interviews identified a need for more effective communication and CRE educational materials. Respondents fully implementing guidelines reported more CFIR constructs focused on the inner setting domain: leadership engagement (i.e. positive culture), relative priority (i.e. importance of problem), available resources (i.e. laboratory resources, staffing), and access to knowledge and information. The ITS analysis included >62 million person-days of acute and long-term care during the study period. 1,794 HO-CRE episodes occurred during the study period with an incidence rate of 0.29 cases/10,000 person-days. After implementation of guidelines in 2015, HO-CRE cases decreased by 0.005 cases/10,000 person-days/month (95% CI -0.007, -0.003, p = 0.0001) from 2015-2017. No significant changes were seen in incidence between 2017 and 2018.

Implications:
Overall, the VA CRE/CP-CRE initiative was associated with reduction in HO-CRE. Most VAMCs are following the CRE/CP-CRE guidelines and staff are knowledgeable about the guidelines. Leadership has an essential role in facilitating successful implementation of the CRE guidelines, specifically promoting a positive culture, providing resources and improving communication.

Impacts:
Our findings directly support effectiveness of guidelines to mitigate CRE, opportunities to expand laboratory testing, and the importance of leadership engagement. Communication of patient CRE status using the new VA Bug Alert tool, which identifies patients with history of MDROs upon admission, may further curb spread of CRE and other MDROs.