Changing the culture of culturing

De-implementation in infection prevention

A common de-implementation intervention in infection prevention is the discontinuation of contact-based precautions for the prevention of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) transmission within a healthcare facility. Contact precautions were widely implemented as control measures to reduce transmission of VRE and MRSA and were considered a basic practice in the SHEA 2014 Update. ^{Reference Calfee, Salgado and Milstone28} During the period since the 2014 guidance was published, alternative strategies for preventing these healthcare-associated infections (HAIs), such as decolonization protocols for MRSA, have emerged as more effective alternatives. ^{Reference Huang29} Simultaneously, other studies have demonstrated patient harms and medical and industrial waste impacts associated with the widespread use of contact precautions and transmission of these pathogens has moved from being primarily hospital-focused to occurring in other settings, including household and community settings. ^{Reference Di Ruscio, Guzzetta and Bjørnholt30,Reference Lee, OYong, LeBrun, Rubin and Miller31} As noted in the first part of this series, clinical medicine is practiced in the setting of constant change. ^{Reference Branch-Elliman, Chambers and Albin1} This change drives the implementation and de-implementation life cycle of infection prevention initiatives, ^{Reference Branch-Elliman, Chambers and Albin1} which must adapt as evidence, context, and environments change.

Given these ongoing changes and advancements, many facilities opted to move forward with de-implementing contact precautions, often leveraging a removal-and-replacement approach (eg, stopping contact precautions and implementing decolonization programs or enhanced hand hygiene programs). ^{Reference Martin, Colaianne and Bridge32–Reference Schrank, Snyder, Davis, Branch-Elliman and Wright34} Barriers to discontinuation of contact precautions can include provider perceptions about personal risk (eg, concern for personal safety and safety of the healthcare personnel’s family members), concern about liability (eg, concern about transmitting MRSA to another patient), existing order sets and facility protocols that reenforce and encourage the practice, and lack of knowledge about new, more effective interventions, among others. As evidence of the role risk and uncertainty play as major barriers to de-implementation initatives, special populations, among which perceived risks of stopping contact precautions are higher (eg, immunocompromised and pediatric populations), are slower to adopt change in the direction of doing less, with providers caring for these groups waiting for additional data to emerge about the “safety” of discontinuation of the practice. The slower change toward discontinuation in these higher-risk populations also highlights another perennial challenge in de-implementation efforts: once a baseline is established, it is quite hard in practice to take something away—even if the evidence supporting that baseline is weak, out of date, or non-existent. Evidence advancements and presentation of that evidence and education are implementation/deimplementation strategies that can be leveraged to support discontinuation but are almost never sufficient as stand-alone strategies to effect real practice change. Several of these identified barriers to discontinuation can be mapped to strategies (eg, ongoing evidence review and dissemination, education about risk, replacement with another more effective intervention, encouraging standard precautions, identification of champions, engagement and pressure from thought leaders) to support de-implementation efforts.

HAI surveillance activities are another example of an infection prevention program that can undergo substantial evolution and lead to positive change. One facility moved from local management of surveillance activities to a centralized program; in other words, this hospital network removed local reporting and replaced it with centralized reporting. ^{Reference Snyder, Wagester and Harris35} Removing surveillance activities from local control freed up local infection prevention practitioners to spend more time on patient-facing activities, leading to perceived improvements in care delivery. ^{Reference Snyder, Wagester and Harris35} In this case, although the surveillance program itself was sustained, the process and mechanism by which it was provided changed, and local surveillance activities were de-implemented in favor of other quality improvement activities. ^{Reference Snyder, Wagester and Harris35}

A final, and controversial, example in infection prevention and control is the use of universal masking policies in healthcare settings. ^{Reference Klompas, Morris, Sinclair, Pearson and Shenoy36} Universal masking was implemented early in the pandemic when limited other options were able to prevent spread and to reduce disease severity. ^{Reference Klompas, Morris and Shenoy37} However, after other tools became available, the downsides of the approach (interpersonal communication and connections, environmental waste, morale, difficulty with effective use and application) were increasingly apparent. ^{Reference Martínez-Sellés, Sánchez and Guillén38,39} Given these changes, facilities across the country variably opted to change their policies about universal masking. Barriers to practice change included perceptions about risk both among patients and providers, political environment and beliefs creating external pressure both in favor of and opposing the policy, conflicting and uncertain evidence, and medical-legal concerns. Thought leaders and influencers in infection prevention also expressed different opinions about the policy, further complicating facility-level decisions about maintaining or de-implementing universal masking requirements. ^{39,Reference Kalu, Henderson, Weber and Haessler40} In the setting of these major barriers to de-implementation, some of the Expert Recommendations for Implementing Change (ERIC) implementation/de-implementation strategies, described in more detail in Part I, ^{Reference Branch-Elliman, Chambers and Albin1,Reference Powell, Waltz and Chinman41} were used to support de-implementation efforts. These included communication with the public through editorials, op-eds, and television interviews, ongoing evidence reviews, educational sessions and listening sessions with colleagues, legal consultations, creations of communities of practice to share experiences and express views, and ongoing surveillance reporting to ensure stable outcomes after discontinuation of the practice. Some of these barriers and challenges may have been avoided had de-implementation plans been integrated into facility and public health responses upfront as part of a dynamic and adaptive process. ^{Reference Branch-Elliman, Elwy and Chambers42} Integration of de-implementation and de-escalation should be considered an essential element of any future emergency response planning. In their piece on dynamic public health policy responses, Branch-Elliman et al. include a practical toolkit for dynamic policy responses that can be applied to support ongoing assessments of specific recommendations and if deimplementation is indicated. ^{Reference Branch-Elliman, Elwy and Chambers42}

As noted in an earlier example, and part of a recurring theme in de-implementation science, once a new baseline is established, resetting that baseline is extremely difficult—humans do not like having things taken away from them, no matter what the context. In healthcare settings—which inherently involve high-risk and high-emotion decisions—this tendency is amplified. Experience and data suggest that the burden of proof shifts toward demonstrating that a practice is ineffective or harmful, rather than the burden of proof resting on establishing that it is effective. Perhaps reflective of the ongoing controversies and disagreements about the evidence among thought leaders, not to mention the background political environment, many healthcare facilities follow local viral disease burden and risk stratification of patient populations (eg, neonates, bone marrow transplant) on when to initiate and de-implement masking during the respiratory season. Although the practice is common, as of this writing, an evidence-based risk threshold above which inpatient masking policies are effective has not been established.

In addition to the examples presented here, a summary of studies that have leveraged implementation and de-implementation principles in infection prevention is presented in Table 1. Though most reflect implementation, they are good examples of how the same theories, models, and frameworks can be used to support de-implementation efforts. For example, Schneider et al studied the implementation of a toolkit for prevention and control of carbapenem-resistant Enterobacteriaceae (CRE). ^{Reference Schneider, Coope, Michie, Puleston, Hopkins and Oliver43} The purpose of the UK CRE toolkit was to empower frontline staff and leadership with information and to recommend process changes. ^{Reference Stokle, Johnson and Woodford44} The CRE toolkit was designed to have strategies to support rapid implementation efforts, but many of the strategies, such as communications strategies, could also be leveraged to support de-implementation efforts once the perceived risk period has elapsed. Ironically, Schneider et al reported that a major limitation of the toolkit was that potential users found that the recommendations and strategies included in the toolkit were impractical (failing the feasibility test) and a lack of trust in the level of evidence included in the recommendations (failing the acceptability test). ^{Reference Schneider, Coope, Michie, Puleston, Hopkins and Oliver43} Additional concerns included uncertainty about risk as well as receiving too much and overly detailed information. ^{Reference Schneider, Coope, Michie, Puleston, Hopkins and Oliver43}

Table 1.

Practical examples of de-implementation science in infection prevention

Note. TMFs, theories, models, and frameworks; RE-AIM, reach, effectiveness, adoption, implementation, maintenance; COM-B, capabilities, opportunities, and motivation to perform a behavior; i-PARiHS, integrated promoting action on research implementation in health services.

Surgical prophylaxis: times change

The Surgical Care Improvement Project (SCIP) was a national quality improvement campaign designed to promote improvements in perioperative care; among the original elements of the SCIP was a recommendation associated with mandated public reporting to discontinue antimicrobials within 24 hours of surgery and within 48 hours for cardiac surgery. ^{Reference Branch-Elliman, Elwy and Lamkin53,Reference Branch-Elliman, Golenbock and Hederstedt54} To achieve compliance with these reporting requirements, facilities adopted a variety of strategies, including order sets, educational programs, and audit and feedback, among others. The antimicrobial use reporting requirement was sunsetted in 2015. During the period since the program ended, guidelines evolved to recommend immediate discontinuation of antimicrobials after surgery rather than permitting post-operative administration. ^{Reference Calderwood, Anderson and Bratzler55} However, processes and physician educational interventions from the original SCIP program, such as order sets embedded into the EHR, remain. ^{Reference Branch-Elliman, Elwy and Lamkin53,Reference Pendergast, Mull and Shin56} Thus, there is a need for additional de-implementation efforts to support the adoption of the new recommendations. Factors that may continue to support the ongoing application of older guidelines include provider concerns about providing sub-standard care (eg, medical-legal concerns), embedded processes that support ongoing use (eg, standardized order sets), and knowledge and understanding about current recommendations. ^{Reference Pendergast, Mull and Shin56} These barriers to change suggest several strategies for promoting de-implementation initiatives, including engagement of IT services to update order sets, educational campaigns, and audit and feedback with benchmarking to demonstrate to providers that discontinuation is within the acceptable standard of care. Support from key, trusted opinion leaders and local experts about the safety of the practice change can also help to provide reassurance to those who are uncomfortable with the immediate discontinuation of prophylaxis.

Dental prophylaxis

Estimates suggest that up to 10% of all antimicrobial use occurs in dental offices; the vast majority of this use is either inappropriate or frankly contraindicated. ^{Reference Suda, Calip and Zhou57,Reference Suda, Fitzpatrick and Gibson58} Reasons for high rates of use in dental settings include lack of knowledge about guidelines, concerns about severe adverse events and medical liability (eg, failure to provide prophylaxis will cause endocarditis), and limited feedback about harms of the treatment. These drivers of practice imply several strategies to support de-implementation initiatives: provider education, improved engagement and linkage to key thought leaders and experts, and better systems of providing feedback about use, current standards of care, and harms of the treatment. Unlike the inpatient setting where these strategies may be more easily deployed, a major challenge in the dental setting is the disconnected, diffuse nature of dental practices and limited linkage to experts who can support the de-implementation efforts. Ongoing studies seek to identify ways to overcome these challenges to improve care. ^{Reference Branch-Elliman, Lamkin and Shin59}

Additional examples of implementation and de-implementation science leading to changes in behaviors and processes in antimicrobial stewardship are presented in Table 2.

Table 2.

Practical examples of de-implementation science in antimicrobial stewardship

Note. TMFs, theories, models, and frameworks; RE-AIM, reach, effectiveness, adoption, implementation, maintenance; COM-B, capabilities, opportunities, and motivation to perform a behavior; i-PARiHS, integrated promoting action on research implementation in health services.