Evaluating implementation of methicillin-resistant Staphylococcus aureus (MRSA) prevention guidelines in spinal cord injury centers using the PARIHS framework: a mixed methods study.
BACKGROUND
To prevent methicillin-resistant Staphylococcus aureus (MRSA) in Spinal Cord Injury and Disorder (SCI/D) Centers, the "Guidelines for Implementation of MRSA Prevention Initiative in the Spinal Cord Injury Centers" were released in July 2008 in the Veterans Affairs (VA) Health Care System. The purpose of this study was to use the Promoting Action on Research Implementation in Health Systems (PARiHS) framework to evaluate the experiences of implementation of SCI/D MRSA prevention guidelines in VA SCI/D Centers approximately 2-3 years after the guidelines were released.


METHODS
Mixed methods were used across two phases in this study. The first phase included an anonymous, web-based cross-sectional survey administered to providers at all 24 VA SCI/D Centers. The second phase included semi-structured telephone interviews with providers at 9 SCI/D Centers. The PARiHS framework was used as the foundation of both the survey questions and semi-structured interview guide.


RESULTS
The survey was completed by 295 SCI/D providers (43.8 % response rate) from 22 of the 24 SCI/D Centers (91.7 % participation rate). Respondents included nurses (57.3 %), therapists (24.4 %), physicians (11.1 %), physician assistants (3.4 %), and other health care professionals (3.8 %). Approximately 36 % of the SCI/D providers surveyed had not seen, did not remember seeing, or had never heard of the MRSA SCI/D guidelines, whereas 42.3 % of providers reported that the MRSA SCI/D guidelines were fully implemented in their SCI/D Center. Data revealed numerous barriers and facilitators to guideline implementation. Facilitators included enhanced leadership support and provider education, focused guideline dissemination to reach SCI/D providers, and strong perceived evidence supporting the guidelines. Barriers included lack of awareness of the guidelines among physical therapists and physician assistants and challenges in cohorting/isolating MRSA-positive patients and following contact precautions.


CONCLUSIONS
Successful implementation of MRSA infection prevention guidelines in SCI/D settings requires (1) guideline dissemination that reaches the full range of SCI/D providers working in inpatient, outpatient, and other care settings, (2) provider education that is frequent and systematic, (3) strong leadership support, and (4) that barriers unique to the recommendations are addressed. These findings may be used to inform selection of implementation strategies and optimize infection prevention beyond MRSA as well as in other specialty care populations.
Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL, USA. Salva.Balbale@va.gov.|Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL, USA. Salva.Balbale@va.gov.|Center for Healthcare Studies, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. Salva.Balbale@va.gov.
Salva N
SN
Balbale
Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL, USA. Jennifer.Hill3@va.gov.|Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL, USA. Jennifer.Hill3@va.gov.
Jennifer N
JN
Hill
Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL, USA. Marylou.Guihan@va.gov.|Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL, USA. Marylou.Guihan@va.gov.|Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. Marylou.Guihan@va.gov.
Marylou
M
Guihan
Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, US Department of Veterans Affairs, Bedford, MA, USA. Timothy.Hogan@va.gov.|eHealth Quality Enhancement Research Initiative, National eHealth QUERI Coordinating Center, Edith Nourse Rogers Memorial Veterans Hospital, US Department of Veterans Affairs, Bedford, MA, USA. Timothy.Hogan@va.gov.|Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA. Timothy.Hogan@va.gov.
Timothy P
TP
Hogan
Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. k-cameron@northwestern.edu.|Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. k-cameron@northwestern.edu.
Kenzie A
KA
Cameron
Patient Care Services, Spinal Cord Injury/Disorders Services, US Department of Veterans Affairs, Seattle, WA, USA. Barry.Goldstein@va.gov.|Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA. Barry.Goldstein@va.gov.
Barry
B
Goldstein
Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL, USA. Charlesnika.Evans@va.gov.|Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL, USA. Charlesnika.Evans@va.gov.|Center for Healthcare Studies, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. Charlesnika.Evans@va.gov.|Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. Charlesnika.Evans@va.gov.
Charlesnika T
CT
Evans
D003430:Cross-Sectional Studies; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus; D017410:Practice Guidelines as Topic; D016730:Program Development; D013119:Spinal Cord Injuries / Q000150:complications / Q000628:therapy*; D013203:Staphylococcal Infections / Q000188:drug therapy / Q000382:microbiology / Q000517:prevention & control*