Evaluation of early implementations of antibiotic stewardship program initiatives in nine Dutch hospitals

Background Antibiotic resistance is a global threat to patient safety and care. In response, hospitals start antibiotic stewardship programs to optimise antibiotic use. Expert-based guidelines recommend strategies to implement such programs, but local implementations may differ per hospital. Earlier published assessments determine maturity of antibiotic stewardship programs based on expert-based structure indicators, but they disregard that there may be valid deviations from these expert-based programs. Aim To analyse the progress and barriers of local implementations of antibiotic stewardship programs with stakeholders in nine Dutch hospitals and to develop a toolkit that guides implementing local antibiotic stewardship programs. Methods An online questionnaire based on published guidelines and recommendations, conducted with seven clinical microbiologists, seven infectious disease physicians and five clinical pharmacists at nine Dutch hospitals. Results Results show local differences in antibiotic stewardship programs and the uptake of interventions in hospitals. Antibiotic guidelines and antibiotic teams are the most extensively implemented interventions. Education, decision support and audit-feedback are deemed important interventions and they are either piloted in implementations at academic hospitals or in preparation for application in non-academic hospitals. Other interventions that are recommended in guidelines - benchmarking, restriction and antibiotic formulary - appear to have a lower priority. Automatic stop-order, pre-authorization, automatic substitution, antibiotic cycling are not deemed to be worthwhile according to respondents. Conclusion There are extensive local differences in the implementation of antibiotic stewardship interventions. These differences suggest a need to further explore the rationale behind the choice of interventions in antibiotic stewardship programs. Rather than reporting this rationale, this study reports where rationale can play a key role in the implementation of antibiotic stewardship programs. A one-size-fits-all solution is unfeasible as there may be barriers or valid reasons for local experts to deviate from expert-based guidelines. Local experts can be supported with a toolkit containing advice based on possible barriers and considerations. These parameters can be used to customise an implementation of antibiotic stewardship programs to local needs (while retaining its expert-based foundation)

Participatory eHealth development to support nurses in antimicrobial stewardship

Background Antimicrobial resistance poses a threat to patient safety worldwide. To stop antimicrobial resistance, Antimicrobial Stewardship Programs (ASPs; programs for optimizing antimicrobial use), need to be implemented. Within these programs, nurses are important actors, as they put antimicrobial treatment into effect. To optimally support nurses in ASPs, they should have access to information that supports them in their preparation, administration and monitoring tasks. In addition, it should help them to detect possible risks or adverse events associated with antimicrobial therapy. In this formative study, we investigate how nurses’ can be supported in ASPs by means of an eHealth intervention that targets their information needs. Methods We applied a participatory development approach that involves iterative cycles in which health care workers, mostly nurses, participate. Focus groups, observations, prototype evaluations (via a card sort task and a scenario-based information searching task) and interviews are done with stakeholders (nurses, managers, pharmacist, and microbiologist) on two pulmonary wards of a 1000-bed teaching hospital. Results To perform the complex antimicrobial-related tasks well, nurses need to consult various information sources on a myriad of occasions. In addition, the current information infrastructure is unsupportive of ASP-related tasks, mainly because information is not structured to match nurse tasks, is hard to find, out of date, and insufficiently supportive of awareness. Based our findings, we created a concept for a nurse information application. We attuned the application’s functionality, content, and structure to nurse work practice and tasks. Conclusions By applying a participatory development approach, we showed that task support is a basic need for nurses. Participatory development proved useful regarding several aspects. First, it allows for combining bottom-up needs (nurses’) and top-down legislations (medical protocols). Second, it enabled us to fragmentise and analyse tasks and to reduce and translate extensive information into task-oriented content. Third, this facilitated a tailored application to support awareness and enhance patient safety. Finally, the involvement of stakeholders created commitment and ownership, and helped to weigh needs from multiple perspective

Business Modeling to Implement an eHealth Portal for Infection Control: A Reflection on Co-Creation With Stakeholders

Background: It is acknowledged that the success and uptake of eHealth improve with the involvement of users and stakeholders to make technology reflect their needs. Involving stakeholders in implementation research is thus a crucial element in developing eHealth technology. Business modeling is an approach to guide implementation research for eHealth. Stakeholders are involved in business modeling by identifying relevant stakeholders, conducting value co-creation dialogs, and co-creating a business model. Because implementation activities are often underestimated as a crucial step while developing eHealth, comprehensive and applicable approaches geared toward business modeling in eHealth are scarce. Objective: This paper demonstrates the potential of several stakeholder-oriented analysis methods and their practical application was demonstrated using Infectionmanager as an example case. In this paper, we aim to demonstrate how business modeling, with the focus on stakeholder involvement, is used to co-create an eHealth implementation. Methods: We divided business modeling in 4 main research steps. As part of stakeholder identification, we performed literature scans, expert recommendations, and snowball sampling (Step 1). For stakeholder analyzes, we performed “basic stakeholder analysis,” stakeholder salience, and ranking/analytic hierarchy process (Step 2). For value co-creation dialogs, we performed a process analysis and stakeholder interviews based on the business model canvas (Step 3). Finally, for business model generation, we combined all findings into the business model canvas (Step 4). Results: Based on the applied methods, we synthesized a step-by-step guide for business modeling with stakeholder-oriented analysis methods that we consider suitable for implementing eHealth. Conclusions: The step-by-step guide for business modeling with stakeholder involvement enables eHealth researchers to apply a systematic and multidisciplinary, co-creative approach for implementing eHealth. Business modeling becomes an active part in the entire development process of eHealth and starts an early focus on implementation, in which stakeholders help to co-create the basis necessary for a satisfying success and uptake of the eHealth technology

Business models for sustained eHealth implementation : lessons from two continents

The original publication is available at http://conferences.sun.ac.za/index.php/cie/cie-42There is general consensus that Computers and Information Technology have the potential to enhance health systems applications, and many good examples of such applications exist all over the world. Unfortunately, with respect to eHealth and telemedicine, there is much disillusionment and scepticism. This paper describes two models that were developed separately, but had the same purpose, namely to facilitate a holistic approach to the development and implementation of eHealth solutions. The roadmap of the Centre for eHealth Research (CeHRes roadmap) was developed in the Netherlands, and the Telemedicine Maturity Model (TMMM) was developed in South Africa. The purpose of this paper is to analyse the commonalities and differences of these approaches, and to explore how they can be used to complement each other. The first part of this paper comprises of a comparison of these models in terms of origin, research domain and design principles. Case comparisons are then presented to illustrate how these models complement one another.Publishers' versio

Nonanastomotic biliary strictures after liver transplantation, part 2:Management, outcome, and risk factors for disease progression

Nonanastomotic biliary strictures (NAS) after orthotopic liver transplantation (OLT) are associated with high retransplant rates. The aim of the present study was to describe the treatment of and identify risk factors for radiological progression of bile duct abnormalities, recurrent cholangitis, biliary cirrhosis, and retransplantation in patients with NAS. We retrospectively studied 81 cases of NAS. Strictures were classified according to severity and location. Management of strictures was recorded. Possible prognostic factors for bacterial cholangitis, radiological progression of strictures, development of severe fibrosis/cirrhosis, graft survival, and patient survival were evaluated. Median follow-up after OLT was 7.9 years. NAS were most prevalent in the extrahepatic bile duct. Twenty-eight patients (35%) underwent some kind of interventional treatment, leading to a marked improvement in biochemistry. Progression of disease was noted in 68% of cases with radiological follow-up. Radiological progression was more prevalent in patients with early NAS and one or more episodes of bacterial cholangitis. Recurrent bacterial cholangitis (> 3 episodes) was more prevalent in patients with a hepaticojejunostomy. Severe fibrosis or cirrhosis developed in 23 cases, especially in cases with biliary abnormalities in the periphery of the liver. Graft survival, but not patient survival, was influenced by the presence of NAS. Thirteen patients (16%) were retransplanted for NAS. In conclusion, especially patients with a hepaticojejunostomy, those with an early diagnosis of NAS, and those with NAS presenting at the level of the peripheral branches of the biliary tree, are at risk for progressive disease with severe outcome

Why Business Modeling is Crucial in the Development of eHealth Technologies

The impact and uptake of information and communication technologies that support health care are rather low. Current frameworks for eHealth development suffer from a lack of fitting infrastructures, inability to find funding, complications with scalability, and uncertainties regarding effectiveness and sustainability. These issues can be addressed by defining a better implementation strategy early in the development of eHealth technologies. A business model, and thus business modeling, help to determine such an implementation strategy by involving all important stakeholders in a value-driven dialogue on what the technology should accomplish. This idea also seems promising to eHealth, as it can contribute to the whole development of eHealth technology. We therefore suggest that business modeling can be used as an effective approach to supporting holistic development of eHealth technologies. The contribution of business modeling is elaborated in this paper through a literature review that covers the latest business model research, concepts from the latest eHealth and persuasive technology research, evaluation and insights from our prior eHealth research, as well as the review conducted in the first paper of this series. Business modeling focuses on generating a collaborative effort of value cocreation in which all stakeholders reflect on the value needs of the others. The resulting business model acts as the basis for implementation. The development of eHealth technology should focus more on the context by emphasizing what this technology should contribute in practice to the needs of all involved stakeholders. Incorporating the idea of business modeling helps to cocreate and formulate a set of critical success factors that will influence the sustainability and effectiveness of eHealth technology