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BMC Health Serv Res. 2019 Oct 12;19(1):689. doi: 10.1186/s12913-019-4492-4.

Implementing a toolkit for the prevention, management and control of carbapenemase-producing Enterobacteriaceae in English acute hospitals trusts: a qualitative evaluation.

Author information

1
University College London, Gower St, Bloomsbury, London, WC1E 6BT, UK. a.schneider@ucl.ac.uk.
2
National Institute for Health Research Health Protection Unit in Evaluation of Interventions, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK. a.schneider@ucl.ac.uk.
3
National Institute for Health Research Health Protection Unit in Evaluation of Interventions, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK.
4
Field Service South West, National Infection Service, Public Health England, 2 Rivergate, Bristol, BS1 6EH, UK.
5
University College London, Gower St, Bloomsbury, London, WC1E 6BT, UK.
6
Field Service East Midlands, National Infection Service, Public Health England, Nottingham, NG24LA, UK.
7
Division of Healthcare-Associated Infection and Antimicrobial Resistance, National Infection Service, Public Health England, London, UK.

Abstract

BACKGROUND:

Antimicrobial resistance is an increasing problem in hospitals world-wide. Following other countries, English hospitals experienced outbreaks of carbapenemase-producing Enterobacteriaceae (CPE), a bacterial infection commonly resistant to last resort antibiotics. One way to improve CPE prevention, management and control is the production of guidelines, such as the CPE toolkit published by Public Health England in December 2013. The aim of this research was to investigate the implementation of the CPE toolkit and to identify barriers and facilitators to inform future policies.

METHODS:

Acute hospital trusts (Nā€‰=ā€‰12) were purposively sampled based on their self-assessed CPE colonisation rates and time point of introducing local CPE action plans. Following maximum variation sampling, 44 interviews with hospital staff were conducted between April and August 2017 using a semi-structured topic guide based on the Capability, Opportunity, Motivation and Behaviour Model and the Theoretical Domains Framework, covering areas of influences on behaviour. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.

RESULTS:

The national CPE toolkit was widely disseminated within infection prevention and control teams (IPCT), but awareness was rare among other hospital staff. Local plans, developed by IPCTs referring to the CPE toolkit while considering local circumstances, were in place in all hospitals. Implementation barriers included: shortage of isolation facilities for CPE patients, time pressures, and competing demands. Facilitators were within hospital and across-hospital collaborations and knowledge sharing, availability of dedicated IPCTs, leadership support and prioritisation of CPE as an important concern. Participants using the CPE toolkit had mixed views, appreciating its readability and clarity about patient management, but voicing concerns about the lack of transparency on the level of evidence and the practicality of implementation. They recommended regular updates, additional clarifications, tailored information and implementation guidance.

CONCLUSIONS:

There were problems with the awareness and implementation of the CPE toolkit and frontline staff saw room for improvement, identifying implementation barriers and facilitators. An updated CPE toolkit version should provide comprehensive and instructive guidance on evidence-based CPE prevention, management and control procedures and their implementation in a modular format with sections tailored to hospitals' CPE status and to different staff groups.

KEYWORDS:

Acute care settings; Antimicrobial resistance; Carbapenem; Complex interventions; Guideline; Hospital infection; Implementation science; Infection prevention and control; Theory-driven evaluation

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