Virginia McKay

Objective: This systematic review aims to describe the impact of specific antimicrobial stewardship program (ASP) strategies on implementation and stewardship-related outcomes. Design: Systematic literature review. Methods: We systematically searched multiple databases using search terms that focused on stewardship and implementation. An original search was completed on October 29, 2021, and then updated on February 26, 2025. Studies were eligible for inclusion if they were in English, reported an antimicrobial resource outcome, and using either a comparison group or a pre/post design as a minimum level of rigor. Data from articles were extracted to understand the context and design of the evaluation, the types of approaches used, and outcomes assessed. Results: Out of 2035 studies that were identified, we included 250 full-text peer-reviewed manuscripts. Of the 250 studies included, 52% were conducted in the USA. The majority (80%) of studies were conducted in inpatient settings, particularly in adult academic hospitals (29%). Programs were often implemented hospital-wide or across multiple specialties, with a focus on emergency medicine and intensive care units. Education or learning (64% of studies) and handshake stewardship (56% of studies) were by far the most common ASP strategies used. Mortality (36% of studies) and drug choice (57% of studies) were the most tracked patient and resource outcomes, respectively. Conclusions: Our review highlights the variability in approaches as part of ASPs, indicating a need for a more systematic understanding of how different approaches are implemented and their subsequent impact on antimicrobial use.

Background/Objectives: Nonpharmaceutical interventions such as social distancing and face mask use were central to controlling infectious disease transmission during the early phases of the COVID-19 pandemic, particularly when vaccines and treatments were limited or unevenly available. Although public health strategies emphasized individual compliance, adherence varied widely. Empirical evidence remains limited regarding how individuals integrate influences across individual, interpersonal, and community levels when assessing their ability and readiness to socially distance. This study examined how residents evaluated, prioritized, and experienced multi-level factors shaping perceived ability and readiness to practice social distancing during the early phase of the COVID-19 epidemic. Methods: We conducted a cross-sectional online survey of adults (≥18 years) residing in St. Louis City and St. Louis County, Missouri, between April and July 2020. Participants selected and ranked individual/interpersonal and community-level factors influencing social distancing and provided open-ended explanations of their choices. Quantitative data were analyzed descriptively to assess selection frequency and ranking priority. Qualitative responses were analyzed using iterative thematic coding to examine how participants interpreted and combined these factors. Results: The analytic sample included 1692 respondents. At the individual/interpersonal level, family and friends’ distancing behavior (58.9%), desire for in-person interaction (52.4%), and personal risk of COVID-19 (48.9%) were frequently selected, while personal risk, caring for others, and ability to work from home were most often ranked as the highest priority. At the community level, others’ distancing in public spaces (66.2%), availability of COVID-19 testing (58.9%), and businesses’ ability to ensure distancing and sanitation (57.2%) were most frequently selected, with epidemic severity, testing availability, and treatment availability ranked as most influential. Qualitative findings indicated that respondents experienced these influences as interconnected, integrating personal and relational risk, local epidemic conditions, healthcare access, visible community norms, and employer policies. Conclusions: Perceived ability and readiness to practice social distancing emerge from interdependent social and structural conditions rather than isolated individual motivations. Public health responses to emerging infectious diseases may be more effective when individual-level guidance is complemented by accessible testing and treatment, supportive workplace policies, and community environments that visibly reinforce protective behaviors.

Background/Objectives: Nonpharmaceutical interventions such as social distancing are critical for controlling infectious disease transmission during emerging epidemics, particularly when pharmaceutical countermeasures are limited or unevenly available. During the early phases of the COVID-19 pandemic, public health strategies emphasized individual compliance, yet adherence varied widely. Empirical evidence remains limited on how individuals integrate influences across individual, interpersonal, and community levels when determining their ability and readiness to socially distance. This study examined how residents evaluated, prioritized, and experienced multi-level factors shaping perceived ability and readiness to practice social distancing during the early phase of the COVID-19 epidemic. Methods: We conducted a cross-sectional online survey of adults (≥18 years) residing in St. Louis City and St. Louis County, Missouri, between April and July 2020. Participants selected and ranked individual/interpersonal and community-level factors influencing social distancing and provided open-ended explanations of their choices. Quantitative data were analyzed descriptively to assess selection frequency and ranking priority. Qualitative responses were analyzed using iterative thematic coding to examine how participants interpreted and combined these factors. Results: The analytic sample included 1,692 respondents. At the individual/interpersonal level, family and friends’ distancing behavior (58.9%), desire for in-person interaction (52.4%), and personal risk of COVID-19 (48.9%) were frequently selected, while personal risk, caring for others, and ability to work from home were most often ranked as highest priority. At the community level, others’ distancing in public spaces (66.2%), availability of COVID-19 testing (58.9%), and businesses’ ability to ensure distancing and sanitation (57.2%) were most frequently selected, with epidemic severity, testing availability, and treatment availability ranked as most influential. Qualitative findings indicated that respondents experienced these influences as interconnected, integrating personal and relational risk, local epidemic conditions, healthcare access, visible community norms, and employer policies. Conclusions: Perceived ability and readiness to practice social distancing emerge from interdependent social and structural conditions rather than isolated individual motivations. Public health responses to emerging infectious diseases may be more effective when individual-level guidance is complemented by accessible testing and treatment, supportive workplace policies, and community environments that visibly reinforce protective behaviors.

Excessive use of postoperative prophylactic antibiotics in children’s hospitals is a significant public health concern, leading to increased risks of infections like Clostridioides difficile, multidrug-resistant organisms, and unnecessary healthcare costs. Antibiotic stewardship programs (ASPs) are designed to optimize antibiotic use, but ideal strategies for implementing evidence-based guidelines remain unclear. We tested facilitation, a dynamic process where trained individuals support healthcare personnel in bridging evidence-practice gaps, as a promising strategy for the de-implementation of unnecessary postoperative antibiotics in healthcare. The OPerAtiC trial employed a stepped-wedge cluster randomized controlled design across nine hospitals to compare the effectiveness of two ASP-led strategies, specifically order set changes to align with antibiotic guidelines (baseline arm) and facilitation training (intervention arm). Facilitation workshops were informed by the i-PARIHS framework, emphasizing context analysis, evidence application, and recipient engagement; and were conducted remotely. Data were collected from 2019 to 2024, involving interviews with stewardship team members every two months. Data collected included proximal implementation outcomes of each ASP team member (acceptability, feasibility, appropriateness), intermediate outcomes (facilitation skill use) reported by the ASP team, and order set change completion rates. Proximal implementation outcomes for both strategies were rated high across all study phases, indicating strong baseline enthusiasm among participants (N = 30). Key facilitation skills—effective communication, conflict resolution, and data presentation—were pivotal for successful implementation. Most order set changes (76%) were completed post-facilitation, targeting various specialties and achieving reductions or eliminations in antibiotic use. Facilitation was associated with significantly more completed order sets targeting antibiotic reduction (p = 0.01), suggesting a potential pathway to improve the appropriateness of antibiotic use through implementation strategies. Facilitation is a valuable approach in refining ASP efforts, contributing to the successful reduction and de-implementation of unnecessary antibiotic use in children's hospitals. The study underscores the need for ongoing training and support for ASP teams to enhance their effectiveness in promoting appropriate antibiotic-prescribing practices. Future research should explore the long-term impacts of facilitation on antibiotic stewardship and patient outcomes. ClinicalTrials.gov ID NCT04366440, https://clinicaltrials.gov/study/NCT04366440?term=OPERATIC&rank=1&tab=history , registered on 04/27/2020.

Background/Objectives: Antimicrobial resistance (AMR) is a major global health threat, with children at higher risk due to developmental differences in drug metabolism, limited treatment options and inappropriate antibiotic use. Pediatric antimicrobial stewardship programs (ASPs) face implementation challenges, often relying on adult-based guidelines and limited pediatric-specific evidence. This study aimed to identify and prioritize the most critical areas for pediatric ASP intervention development through a structured, multi-round Delphi consensus process with experts in antimicrobial stewardship and infectious diseases. Method: A four-round modified Delphi process was conducted to identify and prioritize key pediatric ASP interventions. Experts in antimicrobial stewardship and infectious diseases were recruited through an existing clinical trial. Using an iterative survey and in-person discussions, experts provided input on priority areas, which were thematically grouped and refined across rounds. Structured feedback supported real-time refinement and consensus-building. Results: Twenty experts participated in the process, generating 25 priority items in Round 1 through open-ended responses. These were narrowed to seven key priorities through structured voting and discussion. The final items were clustered into three intersecting themes: Care Settings, Prescriptions, and Strategies. Care Settings focused on high-impact areas such as outpatient clinics and intensive care units, where misuse is common and/or care is complex. The prescriptions theme prioritized shorter durations and narrow-spectrum agents. The strategy theme highlighted the need for outcome-based metrics, improved diagnostic stewardship, and routine tracking of patient outcomes to guide and assess stewardship efforts. Conclusions: This expert consensus identified key priorities for pediatric ASPs, providing a foundation for future interventions. Findings can be used to inform policy and practice, improving the appropriate use of antimicrobials in pediatrics and combating AMR.

While there is evidence of humans’ harmful impact on the environment, translating such evidence into changes is challenging. Implementation science can facilitate a shift from a reactive to proactive approach in tackling environmental sustainability. This article aims to spur further discussion among implementation scientists to incorporate environmental sustainability within their research, while also offering concepts relevant to environmental science researchers seeking to apply implementation science principles.

Background: Acute heart failure (AHF) is associated with high rehospitalization, morbidity, and mortality rates. Implementing medically tailored meal (MTM) interventions may help to optimize nutrition and improve outcomes for patients with AHF. This study aimed to explore facilitators and barriers to implementing an MTM intervention in a tertiary hospital. Methods: From August 2023 to October 2023, we conducted semistructured interviews with health care workers and patients with AHF at Barnes Jewish Hospital in Saint Louis, Missouri. The study used the updated Consolidated Framework for Implementation Research 2.0 to assess 5 domains: MTM characteristics, inner and outer settings, individual characteristics, and implementation process. Audio files were transcribed, and data were analyzed using inductive and deductive approaches. Results: The sample (n=30) consisted of health care workers, including cardiologists (n=5), hospitalists (n=3), nurse practitioners (n=3) and dietitians (n=4), and patients hospitalized for AHF (n=15). Participants identified facilitators including perceived trust in MTM recommendations from providers, potential for improved health outcomes, necessity for dietary compliance, and availability of multidisciplinary teams for implementation. Barriers included the need for further research on MTM efficacy, logistical complexities of MTM implementation, implementation costs, limited funding, and lack of electronic medical record integration. Patient participants had limited knowledge about MTM interventions and highlighted the importance in choosing their prescribed meal options. Conclusions: This study identified facilitators and barriers to implementing an MTM intervention for patients with AHF in a tertiary hospital. Addressing these barriers with contextually relevant strategies could enhance the successful implementation of MTM programs.

Background Excessive use of postoperative prophylactic antibiotics in children’s hospitals is a significant public health concern, leading to increased risks of infections like Clostridioides difficile , multidrug-resistant organisms, and unnecessary healthcare costs. Antibiotic stewardship programs (ASPs) are designed to optimize antibiotic use, but ideal strategies for implementing evidence-based guidelines remain unclear. We tested facilitation, a dynamic process where trained individuals support healthcare personnel in bridging evidence-practice gaps, as a promising strategy for the de-implementation of unnecessary postoperative antibiotics in healthcare. Methods The OPerAtiC trial employed a stepped-wedge cluster randomized controlled design across nine hospitals to compare the effectiveness of two ASP-led strategies, specifically order set changes to align with antibiotic guidelines (baseline arm) and facilitation training (intervention arm). Facilitation workshops were informed by the i-PARIHS framework, emphasizing context analysis, evidence application, and recipient engagement; and were conducted remotely. Data were collected from 2019 to 2024, involving interviews with stewardship team members every two months. Data collected included proximal implementation outcomes of each ASP team member (acceptability, feasibility, appropriateness), intermediate outcomes (facilitation skill use) reported by the ASP team, and order set change completion rates. Results Proximal implementation outcomes for both strategies were rated high across all study phases, indicating strong baseline enthusiasm among participants (N = 30). Key facilitation skills—effective communication, conflict resolution, and data presentation—were pivotal for successful implementation. Most order set changes (76%) were completed post-facilitation, targeting various specialties and achieving reductions or eliminations in antibiotic use. Facilitation was associated with significantly more completed order sets targeting antibiotic reduction (p = 0.01), thereby increasing the appropriateness of antibiotic use. Conclusions Facilitation is a valuable approach in refining ASP efforts, contributing to the successful reduction and de-implementation of unnecessary antibiotic use in children's hospitals. The study underscores the need for ongoing training and support for ASP teams to enhance their effectiveness in promoting appropriate antibiotic-prescribing practices. Future research should explore the long-term impacts of facilitation on antibiotic stewardship and patient outcomes Trial Registration information ClinicalTrials.gov ID NCT04366440, https://clinicaltrials.gov/study/NCT04366440?term=OPERATIC&rank=1&tab=history, registered on 04/27/2020.

Background: In the IMPROVE AKI (A Cluster‐Randomized Trial of Team‐Based Coaching Interventions to Improve Acute Kidney Injury) trial, a combination of team‐based coaching and data‐driven surveillance dashboards reduced the odds of AKI following cardiac catheterization by 46%. The objective of this study was to determine if improvements in AKI outcomes would be sustained after completion of the active intervention. Methods and Results: A 2×2 factorial cluster‐randomized trial with an 18‐month active intervention phase (October 2019–March 2021) and an 18‐month sustainability phase (April 2021–September 2022) conducted among cardiac catheterization laboratories in 20 Veterans Affairs sites. Interventions included team‐based coaching in a virtual learning collaborative or technical assistance, with and without access to an automated surveillance reporting dashboard. Data were collected on procedures involving adult patients undergoing diagnostic coronary angiography or percutaneous coronary interventions and not receiving chronic dialysis. The main outcome was AKI within 7 days of cardiac catheterization among all participants and those with preexisting chronic kidney disease. In addition, survey and focused interview data were collected to understand barriers and facilitators to sustaining AKI improvements. In this phase, 440 of 4160 patients experienced AKI, including 216 of 1260 patients with chronic kidney disease. Compared with technical assistance alone, we observed a reduction in AKI among virtual learning collaborative + automated surveillance reporting sites (adjusted odds ratio, 0.60 [95% CI, 0.42–0.86]). Sites had implemented standardized orders (11), oral and intravenous hydration standing orders (13), and contrast limiting protocols (10). Conclusions: Team‐based coaching coupled with data‐driven surveillance dashboards reduced AKI by 40% during the 18 months after active participation in the trial. Process improvement education, care process standardization, and automated outcome feedback may be effective and durable methods for reducing AKI. Registration: URL: https://clinicaltrials.gov/ ; Unique Identifier: NCT03556293.