Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
BMC Health Services Research
Published in: BMC Health Services Research 1/2019

Open Access 01-12-2019 | Research article

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

Authors: Annegret Schneider, Caroline Coope, Susan Michie, Richard Puleston, Susan Hopkins, Isabel Oliver

Published in: BMC Health Services Research | Issue 1/2019

Login to get access

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 (N = 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.
Appendix
Available only for authorised users
Literature
1.
Munoz-Price LS, Poirel L, Bonomo RA, Schwaber MJ, Daikos GL, Cormican M, et al. Clinical epidemiology of the global expansion of Klebsiella pneumoniae carbapenemases. Lancet Infect Dis. 2013;13:785–96.PubMedPubMedCentralCrossRef
2.
Nordmann P, Dortet L, Poirel L. Carbapenem resistance in Enterobacteriaceae: here is the storm! Trends Mol Med. 2012;18:263–72.PubMedCrossRef
3.
French CE, Coope C, Conway L, Higgins JPT, McCulloch J, Okoli G, et al. Control of carbapenemase-producing Enterobacteriaceae outbreaks in acute settings: an evidence review. J Hosp Infect. 2017;95:3–45.PubMedCrossRef
4.
Hawkey PM, Livermore DM. Carbapenem antibiotics for serious infections. BMJ. 2012;344:1–7.CrossRef
5.
Cantón R, Akóva M, Carmeli Y, Giske C, Glupczynski Y, Gniadkowski M, et al. Rapid evolution and spread of carbapenemases among Enterobacteriaceae in Europe. Clin Microbiol Infect. 2012;18:413–31.PubMedCrossRef
6.
Nordmann P. Carbapenemase-producing Enterobacteriaceae: overview of a major public health challenge. Med Mal Infect. 2014;44:51–6.PubMedCrossRef
7.
ECDC. Risk assessment on the spread of carbapenemase-producing Enterobacteriaceae (CPE) through patient transfer between healthcare facilities, with special emphasis on cross-border transfer. Stockholm: ECDC; 2011.
8.
Falagas ME, Tansarli GS, Karageorgopoulos DE. Deaths attributable to Enterobacteriaceae infections. Emerg Infect Dis. 2014;20:6.CrossRef
9.
Van der Bij AK, Pitout JDD. The role of international travel in the worldwide spread of multiresistant enterobacteriaceae. J Antimicrob Chemother. 2012;67:2090–100.PubMedCrossRef
10.
PHE. Acute trust toolkit for the early detection, management and control of carbapenemase-producing Enterobacteriaceae. London: PHE; 2013.
11.
12.
Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. Br Med J. 2015;350:h1258.CrossRef
13.
Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M, et al. Developing and evaluating complex interventions: new guidance. Br Med J. 2008;337:a1655.CrossRef
14.
Chandler CIR, Reynolds J, Palmer JJ, Hutchinson E. ACT consortium guidance: qualitative methods for international health intervention research. London: LSHTM; 2013.
15.
Oakley A, Strange V, Bonell C, Allen E, Stephenson J, Team RS. Process evaluation in randomised controlled trials of complex interventions. Br Med J. 2006;332:413–6.CrossRef
16.
Michie S, van Stralen MM, West R, Grimshaw J, Shirran L, Thomas R, et al. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.PubMedPubMedCentralCrossRef
17.
Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, et al. A guide to using the theoretical domains framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12:77.PubMedPubMedCentralCrossRef
18.
Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:37.PubMedPubMedCentralCrossRef
19.
Coope CM, Verlander NQ, Schneider A, Hopkins S, Welfare W, Johnson AP, et al. An evaluation of a toolkit for the early detection, management, and control of carbapenemase-producing Enterobacteriaceae: a survey of acute hospital trusts in England. J Hosp Infect. 2018;99:381–9.PubMedCrossRef
20.
NICE Guidelines. Behaviour change: general approaches. London: NICE; 2007.
21.
Silverman D. Interpreting qualitative data: a guide to the principles of qualitative research. 4th ed. Los Angeles: Sage; 2011.
22.
Healthcare Quality Improvement. Criteria and indicators of best practice in clinical audit. London: Healthcare Quality Improvement; 2009.
23.
Bryman A. Social research methods. 4th ed. Oxford: Oxford University Press; 2012.
24.
Forrester MA. Doing qualitative research in psychology : a practical guide. Los Angeles: SAGE; 2010.
25.
Lyons E, Coyle A. Analysing qualitative data in psychology. Los Angeles: SAGE Publications; 2007.CrossRef
26.
Akova M, Daikos GL, Tzouvelekis L, Carmeli Y. Interventional strategies and current clinical experience with carbapenemase-producing gram-negative bacteria. Clin Microbiol Infect. 2012;18:439–48.PubMedCrossRef
27.
Johl SK, Renganathan S. Strategies for gaining access in doing fieldwork: reflection of two researchers. Electron J Bus Res Methods. 2010;8:42–50.
28.
29.
Suri H. Purposeful sampling in qualitative research synthesis. Qual Res J. 2011;11:63–75.CrossRef
30.
Boyatzis RE. Transforming qualitative information: thematic analysis and code development. Thousand Oaks: Sage; 1998.
31.
Harper D, Thompson AR. Qualitative research methods in mental health and psychotherapy: a guide for students and practitioners. Chichester, West Sussex: John Wiley & Sons; 2012.
32.
USAID. Conducting key informant interviews. Washington, D.C.: USAID; 1996.
33.
Creswell JW. Qualitative inquiry and research design: choosing among five approaches. 3rd ed. London: SAGE; 2013.
34.
Richards L. Handling qualitative data: a practical guide. 2nd ed. London: SAGE; 2009.
35.
Davies R, Dart J. The ‘Most significant change’ (MSC) technique. London: MSC Guide; 2005.
36.
Chandler CI, DiLiberto D, Nayiga S, Taaka L, Nabirye C, Kayendeke M, et al. The PROCESS study: a protocol to evaluate the implementation, mechanisms of effect and context of an intervention to enhance public health centres in Tororo, Uganda. Implement Sci. 2013;8:113.PubMedPubMedCentralCrossRef
37.
Crilly N, Blackwell AF, Clarkson PJ. Graphic elicitation: using research diagrams as interview stimuli. Qual Res. 2006;6:1–27.CrossRef
38.
NVivo 12 qualitative data analysis software: QSR International Pty Ltd; 2018.
39.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.CrossRef
40.
Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. London: Weidenfeld & Nicolson; 1968.
41.
Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117.PubMedPubMedCentralCrossRef
42.
Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2006;5:80–92.CrossRef
43.
Attride-Stirling J. Thematic networks: an analytic tool for qualitative research. Qual Res. 2001;1:385–405.CrossRef
44.
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32- item checklist for interviews and focus group. Int J Qual Heal Care. 2007;19:349–57.CrossRef
45.
Donker T, Henderson KL, Hopkins KL, Dodgson AR, Thomas S, Crook DW, et al. The relative importance of large problems far away versus small problems closer to home: insights into limiting the spread of antimicrobial resistance in England. BMC Med. 2017;15:1–11.CrossRef
46.
Braithwaite J, Churruca K, Long JC, Ellis LA, Herkes J. When complexity science meets implementation science: a theoretical and empirical analysis of systems change. BMC Med. 2018;16:1–14.CrossRef
47.
48.
Sanders T, Foster NE, Ong BN. Perceptions of general practitioners towards the use of a new system for treating back pain: a qualitative interview study. BMC Med. 2011;9:49.PubMedPubMedCentralCrossRef
49.
Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Int J Technol Assess Heal Care. 2005;21:149.CrossRef
50.
Grol R, Grimshaw J. Research into practice I From best evidence to best practice : effective implementation of change in patients care. Lancet. 2003;362:1225–30.PubMedCrossRef
51.
West MA, Dawson JF. Employee engagement and NHS performance. London: The King’s Fund; 2012.
52.
Fulop N, Walters R, Perri, Spurgeon P. Implementing changes to hospital services: Factors influencing the process and “results” of reconfiguration. Health Policy. 2012;104:128–35.PubMedCrossRef
53.
Williams B, Perillo S, Brown T. What are the factors of organisational culture in health care settings that act as barriers to the implementation of evidence-based practice? A scoping review. Nurse Educ Today. 2015;35:e34–41.PubMedCrossRef
54.
Hussein K, Rabino G, Eluk O, Warman S, Reisner S, Geffen Y, et al. The association between infection control interventions and carbapenem-resistant Enterobacteriaceae incidence in an endemic hospital. J Hosp Infect. 2017;97:218–25.PubMedCrossRef
55.
56.
CDC. Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE). Atlanta: CDC; 2015.
57.
Ferguson KJ, Waitzkin H, Beekmann SE, Doebbeling BN. Critical incidents of nonadherence with standard precautions guidelines among community hospital-based health care workers. J Gen Intern Med. 2004;19:726–31.PubMedPubMedCentralCrossRef
58.
Kastner M, Bhattacharyya O, Hayden L, Makarski J, Estey E, Durocher L, et al. Guideline uptake is influenced by six implementability domains for creating and communicating guidelines: a realist review. J Clin Epidemiol. 2015;68:498–509.PubMedCrossRef
59.
Magiorakos AP, Burns K, Rodríguez Baño J, Borg M, Daikos G, Dumpis U, et al. Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control. Antimicrob Resist Infect Control. 2017;6:1–17.CrossRef
60.
WHO. Guidelines for the prevention and control of carbapenem-resistant Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa in health care facilities. Geneva: WHO; 2017.
61.
PHE. Toolkit for managing carbapenemase- producing Enterobacteriaceae in non- acute and community settings. London: PHE; 2015.
62.
Kim NH, Han WD, Song KH, Seo HK, Shin MJ, Kim TS, et al. Successful containment of carbapenem-resistant Enterobacteriaceae by strict contact precautions without active surveillance. Am J Infect Control. 2014;42:1270–3.PubMedCrossRef
63.
Parker V, Logan C, Currie B. Carbapenem-resistant Enterobacteriaceae (CRE) control and prevention toolkit. Rockville: Agency for Healthcare Research and Quality; 2014.
64.
Bosse G, Breuer JP, Spies C. The resistance to changing guidelines - what are the challenges and how to meet them. Best Pract Res Clin Anaesthesiol. 2006;20:379–95.PubMedCrossRef
65.
Otter JA, Burgess P, Davies F, Mookerjee S, Singleton J, Gilchrist M, et al. Counting the cost of an outbreak of carbapenemase-producing Enterobacteriaceae: an economic evaluation from a hospital perspective. Clin Microbiol Infect. 2017;23:188–96.PubMedCrossRef
66.
Bartsch SM, Huang SS, McKinnell JA, Wong KF, Mueller LE, Miller LG, et al. The economic value of the Centers for Disease Control and Prevention Carbapenem-resistant Enterobacteriaceae toolkit. Infect Control Hosp Epidemiol. 2018;39:516–24.PubMedPubMedCentralCrossRef
67.
Legitimising the Subjectivity of Human Reality Through Qualitative Research Method. Qual Rep. 2003;8:70–80.
68.
Adams A, Cox AL. Questionnaires, in-depth interviews and focus groups. In: Cairns P, Cox AL, editors. Research methods for human computer interaction. Cambridge: Cambridge University Press; 2008. p. 17–34.CrossRef
69.
Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:979–83.CrossRef
Metadata
Title
Implementing a toolkit for the prevention, management and control of carbapenemase-producing Enterobacteriaceae in English acute hospitals trusts: a qualitative evaluation
Authors
Annegret Schneider
Caroline Coope
Susan Michie
Richard Puleston
Susan Hopkins
Isabel Oliver
Publication date
01-12-2019
Publisher
BioMed Central
Published in
BMC Health Services Research / Issue 1/2019
Electronic ISSN: 1472-6963
DOI
https://doi.org/10.1186/s12913-019-4492-4

Other articles of this Issue 1/2019

BMC Health Services Research 1/2019 Go to the issue

Research article

Factors associated with post-acute discharge location after hospital stay: a cross-sectional study from a Swiss hospital

Research article

Algorithms to identify COPD in health systems with and without access to ICD coding: a systematic review

Research article

Estimating the effectiveness and cost-effectiveness of establishing additional endovascular Thrombectomy stroke Centres in England: a discrete event simulation

Research article

Towards a definition of male partner involvement in the prevention of mother-to-child transmission of HIV in Uganda: a pragmatic grounded theory approach

Research article

Adaption and validation of Nijmegen continuity questionnaire to recognize the influencing factors of continuity of care for hypertensive patients in China

Research article

Evaluating the impact of the single exit price policy on a basket of originator medicines in South Africa from 1999 to 2014 using a time series analysis