Developing a Toolkit to Reduce Infections Following Durable LVAD Implantation in the United States Using a Multistage Mixed Methods Design

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Abstract
BACKGROUND: Infections following durable left ventricular assist device (dLVAD) implantation are common and associated with increased morbidity and mortality. Despite documented interhospital variability, few studies have identified strategies to mitigate their occurrence. This national study uses a multistage mixed methods design to develop a customizable and deployable toolkit of expert-guided recommendations to reduce infections post-dLVAD. METHODS: Using purposeful sampling, participants (eg, clinical and operational ventricular assist device [VAD] team members) from low, medium, and high-performance hospitals (based on their risk-adjusted, 90-day post-implantation infection rates) across the United States were interviewed to assess factors contributing to postdLVAD infections. Draft toolkit recommendations were iteratively developed after integrating thematically analyzed qualitative and quantitative data from a merged national registry with Medicare and hospital survey data. A national advisory team of VAD subject matter experts provided mixed methods input to refine the toolkit’s content and structure. RESULTS: Seventy-three clinical and operational VAD team members across 8 US hospitals were interviewed, spanning low (n=4), medium (n=1) and high (n=3) performance groups. Fourteen subject matter experts provided stakeholder feedback to refine the toolkit. The resulting toolkit contains 39 infection prevention recommendations that address VAD program care processes (eg, real-time provider communication), clinicians (eg, multidisciplinary protocol development), patients and caregivers (eg, engaging patient advisors in patient education), and VAD leadership (eg, unit and service level data reporting). Accompanying resources (eg, team-based exercises, data collection worksheets) support implementing and evaluating site-specific strategies. CONCLUSIONS: Using mixed methods approaches, an infection prevention toolkit was developed to enhance care coordination among VAD team members and mitigate postdLVAD infections. Future work should evaluate the effectiveness of implementing this infection prevention toolkit within the dLVAD setting.

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