Implementation activities
A total of 340 educational sessions were provided at the four sites participating in the Prevent CDI-55 + study, and included more than 1,800 key partners and participants.
Adherence to the probiotic prescribing in hospital ranged from 76.9%—84.6% when stratified by study sites and time periods. When evaluating timing of probiotic administration, adherence within 48 h of antibiotic administration ranged from 60.2% to 71.4%, and within 72 h ranged from 66.7% to 75.8%.
Focus groups
Two focus groups and 7 interviews (20 to 60 min in duration) were conducted with a total of 15 participants (1 to 6 participants per group). Of the 15 participants, 4 were registered nurses, 1 was a clinical nurse educator, 3 were physicians, and 7 were pharmacists. One focus group and 3 interviews took place at the SHC from May to August 2017, 3 interviews were conducted at the RGH between March and April 2018, 1 interview was conducted at the PLC in June 2019, and 1 focus group was conducted at the FMC in July 2019.
Themes and subthemes were identified across the CFIR and TDF behaviour change domains. Themes identified relating to the domain of environmental context and resources included process implementation and intervention characteristics. Identified barriers to process implementation were the alert system, medication time, and workload. Regarding the alert system, one participant stated: “The alert fatigue is a well-known problem with SCM so I’m not sure there’s necessarily a way around it with this initiative—like I said unless you made them look a lot different than other alerts. I think, well a lot of times they do get ignored they are probably having some effect.” In terms of medication time, a participant said: “Well I think the gap is that people you schedule medications for 8am but you have several patients and so only one person truly gets them at 8am.” Among the facilitators identified for process implementation, subthemes included patient teaching, order sets, and initiative communication. One participant commented: “The more efficient ways to make it really efficient for the physicians, to not have several extra steps if they want to order it. So, having all that [Bio-K + ®] in the order set with the antibiotic is really good for compliance so you don't have to think about it you just order it.”
Subthemes of intervention characteristics that were identified as barriers included price, pill size, and post-discharge compliance. While Bio-K + ® was provided to patients in hospital, patients would have to purchase Bio-K + ® once they were discharged from hospital (to complete their five day post-antibiotic course), and staff were concerned that patients would be disinclined to purchase or unable to afford it, reducing post-discharge compliance. One participant noted: “On discharge for some people especially like completing the protocol as it’s written. For a lot of people they’ll get it while they’re in hospital but will maybe step down their antibiotics to an oral antibiotic and they are ready to go home and only have 1–2 days of antibiotic left. So technically they have another 5–6 days of Bio-K + ® to finish and they aren’t going to be able to get Bio-K + ® at their nursing home.” In addition, staff commented that the size of the Bio-K + ® capsule was a barrier: “There’s lots of times they just outright refuse. I have had patients who’ve tried to take them and spit them back out because they can’t swallow them.”
Knowledge barriers that were identified included health care provider education, literature, and evidence. Attending physicians were unsure if the medical residents had the same level of training and education on Prevent CDI-55 + , such as the inclusion criteria for patients. In addition, some participants were concerned about the evidence for probiotics: “I know lots of physicians expressed that it’s controversial. Probiotics are a controversial field. Because it’s controversial it ranks low on their list of priorities as well sometimes.” However, literature and evidence were also noted as a facilitator by a participant, in addition to patient education: “I just say it's a probiotic that helps to counteract the effects of the antibiotics and to replenish the good bacteria in your body. And I say it's like eating yogurt but way stronger.”
Barriers related to social and professional role and identity included the physician’s role, the nurse’s role, and the pharmacist’s role. Nurse and pharmacist participants noted that they could suggest to the physician to prescribe Bio-K + ®, however, they could not start a patient on Bio-K + ® independently. However, nurse and pharmacist participants also noted this as a facilitator to Bio-K + ® prescribing: “I know at hand over I just I mindfully remember, I’ll pay attention to patients who are on antibiotics and right away I’ll ask if Bio-K + ® needs to be started so during my shift I can make sure those are started. So that’s what encourages me to look into and get Bio-K + ® started.”
Table
2 lists the identified barriers, facilitators, and changes that were made to address the barriers and facilitators during the Prevent CDI-55 + study. Based on the results of the focus groups, a number of implementation initiatives were adapted to minimize potential barriers to the uptake of Bio-K + ® in Prevent CDI-55 + . The first adaptation was to the pop-up alert in SCM that reminded clinicians to prescribe Bio-K + ® when a therapeutic antibiotic was ordered. The alert was updated to make it more user friendly to ensure Bio-K + ® could be prescribed with one click. In addition, education for nursing staff was updated to address patients not being able to swallow Bio-K + ®; nursing staff was educated that the capsule could be opened and the contents added to food or liquid for administration. Lastly, to ensure patients could access Bio-K + ® after being discharged from hospital, patients were provided with a list of pharmacies that sold Bio-K + ®.
Table 2
Reported barriers, facilitators, and implemented changes
Process implementation | Barrier: alert system, alert fatigue | Updated the originally developed alert that popped up when a therapeutic antibiotic was ordered to ensure Bio-K + ® could be ordered with one click |
Barrier: timing of probiotic administration | Timing of administration was modified wherever possible to minimize barrier |
Barrier: workload | Researchers attempted to minimize the impact to workload based on the changes listed in this table |
Facilitator: patient teaching | All patients received an information package on the Prevent CDI-55 + study |
Facilitator: Order sets | An alert was created within the electronic order entry system to ensure Bio-K + ® could be ordered with one click when a therapeutic antibiotic was ordered |
Facilitator: Initiative communication | Information regarding the Prevent CDI-55 + study, as listed in the methods section, was provided on a regular basis at each study site throughout the duration of the study |
Intervention characteristics | Barrier: price of probiotic | No changes were made |
Barrier: probiotic capsule size | Nursing staff was provided education regarding opening the capsule and sprinkling the contents on food or in liquid for administration |
Barrier: post-discharge compliance | Patients were provided with a list of pharmacies that sold Bio-K + ® |
Knowledge | Barrier: health care provider education | Ongoing health care provider education was provided during the Prevent CDI-55 + study |
Barrier: literature and evidence for probiotics | Information packages, and print and web-based materials were created and available to all AHS staff |
Social and professional role | Barrier and facilitator: role of the health care providers | No changes were made |