Standard versus enhanced implementation strategies to increase adoption of a multidrug-resistant organism (MDRO) alert tool: A cluster randomized trial

Cara Ray^1*Cassie Goedken²Ashley M. Hughes^1,3Geneva M. Wilson^1,4Natalie R. Hicks⁵Margaret A. Fitzpatrick^6,7Makoto M. Jones⁸Christopher Pfeiffer^10,9James Stacey Klutts^11,12,13Martin E. Evans⁵Katie Joy Suda^14,15Charlesnika Evans^1,4

• ¹Edward Hines Jr. VA Hospital, Center of Innovation for Complex Chronic Healthcare, Hines, IL, United States
• ²Iowa City VA Medical Center, Center for Access and Delivery Research and Evaluation, United States Department of Veterans Affairs, Iowa City, Iowa, United States
• ³Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States
• ⁴Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
• ⁵VA National Infectious Diseases Service, MDRO Prevention Division, Washington, DC, United States
• ⁶Rocky Mountain Regional VA Medical Center, Center of Innovation for Veteran Centered and Value Driven Care, Aurora, CO, United States
• ⁷University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
• ⁸VA Salt Lake City Health Care System, Informatics, Decision Enhancement, and Analytics Sciences Center, Salt Lake City, Utah, United States
• ⁹VA Portland Healthcare System, Portland, OR, United States
• ¹⁰Oregon Health and Science University, Portland, Oregon, United States
• ¹¹VA National Pathology and Laboratory Medicine Program Office, Washington, DC, United States
• ¹²Iowa City VA Medical Center, Iowa City VA Health Care System, Veterans Health Administration, United States Department of Veterans Affairs, Iowa City, Iowa, United States
• ¹³Carver College of Medicine, The University of Iowa, Iowa City, Iowa, United States
• ¹⁴Center for Health Equity Research and Promotion, Pittsburgh, PA, United States
• ¹⁵Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States

BackgroundThe Veterans Health Administration (VHA) launched VA Bug Alert (VABA) to identify admitted patients who are infected or colonized with multidrug-resistant organisms (MDROs) in real time and promote timely infection prevention measures. However, initial VABA adoption was suboptimal. The objective of this project was to compare the effectiveness of standard versus enhanced implementation strategies for improving VABA adoption. Methods121 VA healthcare facilities were evaluated for adoption of VABA (at least 1 user registered at a facility) April 2021 – September 2022. All facilities initially received standard implementation, which included: VABA revisions based on end-user feedback, education, and internal facilitation via monthly meetings with the MDRO Prevention Division of the VHA National Infectious Diseases Service. Surveys evaluated VABA perspectives among MDRO Prevention Coordinators (MPCs) and/or Infection Preventionists (IPs) before and after initial standard implementation. Facilities not registered for VABA following initial standard implementation (n=31) were cluster-randomized to continue to receive standard implementation or enhanced implementation (audit and feedback reports and external facilitation via guided interviews to assess VABA use barriers). Percentages of facilities adopting VABA at baseline, after standard implementation (Follow-up 1), and after the enhanced vs. standard implementation trial period (Follow-up 2) were assessed and compared across time points using McNemar's test. VABA adoption was compared by trial condition using Fisher's exact test.ResultsBefore education, 25% of 167 MPC/IP survey respondents across 116 facilities reported no knowledge/use of VABA. After education, 82% of 92 survey respondents across 80 facilities reported intending to use VABA. At baseline, VABA registrations were 40%. Registrations significantly increased aft Follow-up 1(75%, p<0.01) and at Follow-up 2 (89%, p<0.01). Adoption did not significantly differ by assigned implementation condition but was higher among facilities that completed all components of enhanced implementation than those who did not (87.5% vs 43.5%, p=0.045). Guided interviews revealed key facilitators of VABA registration, which included perceived fit, implementation activities, and organizational context (e.g., staffing resources).ConclusionsImplementation efforts dramatically increased VABA registrations. Incorporating interview feedback to increase VABA's fit with users' needs may increase its use and help reduce MDRO spread in VA.