Promoting De-Implementation of Inappropriate Antimicrobial Use in Cardiac Device Procedures By Expanding Audit and Feedback

Background: Cardiac device procedures, such as pacemaker and defibrillator placements, are common and
increasing as the population ages. These devices are life-saving for the Veterans who need them, but the pro-
cedures can be complicated by highly morbid infections and other adverse events, resulting in poor outcomes.
Clinical guidelines recommend administration of pre-procedural antimicrobials to prevent cardiac device infec-
tions and early discontinuation of antimicrobials after the procedure to prevent harms caused by unnecessary
antimicrobial use, such as kidney injury, C. difficile infections, and antimicrobial resistance. However, these
guidelines are rarely applied, resulting in preventable morbidity and mortality, and creating a critical need for
research investigating strategies to promote adoption of best practices (e.g., learning) and de-adoption of inef-
fective and harmful practices (e.g., unlearning).
Significance/Impact: The research in this study closes an important gap in the care of cardiac device recipients
and advances several VA HSR&D research priorities, including implementation, informatics, and quality of care.
It leverages the strength of the VA electronic health record (EHR) and will provide important insights into clinical
informatics methodologies for expanding surveillance of healthcare-associated infections and antimicrobial use
to include outpatient and procedural areas. Investigators will also promote understanding about how learning
and unlearning processes can be leveraged to enhance adoption of clinical guidelines and de-implementation of
ineffective and harmful practices.
Innovation: The highly innovative, informatics-based audit and feedback system will advance the field of imple-
mentation science by yielding a new strategy for promoting de-implementation of inappropriate practices. Les-
sons learned about how to implement novel, real-time informatics tools and adapt and scale them will also be
generalizable to procedural areas with limited resources to support surveillance.
Aim I: Tests the hypothesis that a multi-faceted implementation strategy including automated audit and feed-
back, education of electrophysiology team members, local adaptation, and blended facilitation with engagement
of local champions, will improve adoption of antimicrobial prophylaxis guidelines for electrophysiology proce-
dures at three VA facilities, using a stepped-wedge, Hybrid III design. Primary outcome is adoption of guideline-
recommended antimicrobial use. Clinical effectiveness will be assessed through measurement of clinical out-
comes (CIED infections, AKI, and C. difficile).
Aim II: Measures the feasibility of using an informatics-based algorithm to measure outcomes and guideline-
concordance following cardiac device procedures at 78 facilities and tests the passive diffusion of reports.
Methodology: There is a major gap in studies evaluating de-implementation of ineffective practices. This study
has two complimentary aims and will address this gap by testing the utility of a highly innovative clinical infor-
matics tool developed using the robust VA EHR. The informatics tool combines feedback about best practices
and positive clinical outcomes (learning) with feedback about ineffective and harmful practices and adverse clin-
ical outcomes (unlearning) as part of a multi-faceted implementation strategy. Aim I will test the multi-faceted
implementation strategy at three VAs using a Hybrid III design. Aim II will test the tool’s scalability and dissemi-
nation throughout the VA and will identify barriers to expansion and potential solutions.
Implementation/Next Steps: The central aim of this study is to implement ways to promote best practices. Tools
developed during the course of the study will be widely disseminated throughout the VA to enhance the quality
of care and will be provided to key operational partners, who can adapt the clinical informatics tools to promote
best practices in other clinical cares with limited infection prevention and stewardship resources.

Grant Number: 5I01HX003234-05
NIH Institute/Center: VA
Principal Investigator: Westyn Branch-Elliman