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Table 1 Relationship between iPARIHS Constructs and the Research Plan and Selected Multi-Faced Implementation Strategy

From: Promoting de-implementation of inappropriate antimicrobial use in cardiac device procedures by expanding audit and feedback: protocol for hybrid III type effectiveness/implementation quasi-experimental study

iPARIHS construct

Relationship to research plan/implementation strategies

Innovation

Underlying knowledge

Evidence supporting prevention practices is strong, as evidenced by inclusion of recommendations for pre-incisional prophylaxis with early discontinuation in guidelines endorsed by multiple societies and guideline-issuing bodies. The strength of the evidence supports the viability of a program designed to facilitate uptake of proven effective antimicrobial use.

Compatibility

There are limited local resources dedicated to surveillance and other prevention activities. Our study design, using a centralized automated system with adjudication and validation at a central site, bypasses these resource restraints.

Usability

Local practice patterns and variability may impact how surveillance reports are used; thus, a 6-month local adaptations and piloting phase is included to enhance usability and facilitate uptake. Sites will also have the opportunity to provide feedback about usability and operability of the electronic data monitoring tool at their own site, and to request local adaptations.

Observable results

All variables that will be included in the tool are extractable from the rich VA EHR. Variables that will be extracted electronically include number of procedures with and without guideline-concordant pre-procedure prophylaxis and guideline-discordant post-procedure prophylaxis and facility rank, 90-day CIED infection rate and facility rank, 7-day incidence of acute kidney injury, 90-day incidence of C. difficile infection. Manual review will be used to augment the electronic data pull, and qualitative analysis will be used to enrich the quantitative data.

Recipients

Motivation, values, and beliefs

Clinicians express a desire to ensure their patients have the best outcomes. This implementation strategy highlights the safety of stopping antimicrobials- and that stopping antimicrobials improves the overall health of their patients by (1) not increasing risk of infection, and (2) decreasing the incidence of patient-level antibiotic-associated adverse events (e.g., acute kidney injuries, C. difficile infections, others).

Time, resources, support

Data will be collected through a centralized, automated detection and reporting system with manual adjudication performed at the primary study site. Because local resources and IT support are not required, time, resources, and support required to use the centralized system are low for the participating sites and champions.

Local opinion leaders, Policy Makers

Infectious diseases champions are drivers of practice change and local protocol changes. To leverage the importance of these knowledge leaders, we have the support of policy-making organizations. In addition, process and outcome reports will be provided to local champions to facilitate practice improvements.

Context

Culture

Electrophysiologists commonly conform to local culture about prevention strategies and express concerns about being an “outlier.” Benchmarking is included to demonstrate that the provider is not “an outlier.”

Evaluation and feedback

Audit and feedback reports will be used to demonstrate to providers that a transition to guideline-concordant recommendations is not harmful to patients, and in fact, improves care.

Facilitation

Internal

Local champions will provide input into fidelity-consistent modifications to the audit and feedback reports. Local content experts will serve as facilitators of change, using the data provided and leveraging their status as content and thought leaders. These local experts are also able to write and change local protocols and thus mandate a larger local culture change.

External

External facilitation will involve education, central data collection and adjudication of output from the electronic surveillance algorithm, adjustments to the algorithm based on feedback from sites to improve accuracy and data analysis. The aims of the external facilitation will be to reduce the local burden of surveillance, feedback, and development of educational materials on the intervention sites such that implementation is feasible.