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Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
Department of General Practice, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, the NetherlandsNIVEL (Netherlands Institute for Health Services Research (NIVEL), Utrecht, the Netherlands
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the NetherlandsNational Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, the NetherlandsNational Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
Address correspondence to Laura W. van Buul, PhD, Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Room MF C-370, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands.
Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
This study evaluated logistics, process data, and barriers/facilitators for the implementation and use of C-reactive protein point-of-care testing (CRP POCT) for suspected lower respiratory tract infections (LRTIs) in nursing home (NH) residents.
Design
This process evaluation was performed alongside a cluster randomized, controlled trial (UPCARE study) to evaluate the effect of CRP POCT on antibiotic prescribing for suspected LRTIs in NH residents.
Setting and Participants
Eleven NHs in the Netherlands.
Methods
Data sources for process data regarding intervention quality included a questionnaire among NH staff, logs, reports, and CRP POCT-analyzer records. Barriers and facilitators for implementation were assessed in focus group interviews with physicians and nurses from 3 NHs.
Results
Correct patient selection for CRP POCT and generally continued CRP POCT use indicated good fidelity. The initial training and training of new employees seemed to fit the need, but some POCT-user group sizes had increased over time, which could have impeded frequent use. Users were generally satisfied with CRP POCT and perceived its use feasible and relevant. Facilitators for implementation were initial commitment and active initiation, followed by continued attention and enthusiasm for building routine practice and trust. Short lines of communication between staff, short distance to the POCT-analyzer, 24/7 coverage of staff, and a clear task division facilitated continued attention and routine practice.
Conclusions and Implications
This process evaluation showed sufficient quality of providing CRP POCT in Dutch NHs. We processed findings of intervention quality and implementation knowledge into key recommendations for CRP POCT implementation in this setting. Future research could focus on CRP POCT use in countries with different organization of care in NHs.
Common infections in nursing home (NH) residents such as lower respiratory tract infections (LRTIs) are difficult to diagnose due to atypical clinical presentation in the older patients and limited diagnostic options in this setting.
Defining characteristics and risk indicators for diagnosing nursing home-acquired pneumonia and aspiration pneumonia in nursing home residents, using the electronically-modified Delphi Method.
Point-of-care testing (POCT) to rapidly assess the level of acute inflammatory marker C-reactive protein (CRP) might improve appropriateness of antibiotic prescribing by providing physicians information on presence and severity of infection.
Usefulness of C-reactive protein testing in acute cough/respiratory tract infection: An open cluster-randomized clinical trial with C-reactive protein testing in the intervention group.
Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: Cluster randomised trial.
The association of serum procalcitonin and high-sensitivity C-reactive protein with pneumonia in elderly multimorbid patients with respiratory symptoms: Retrospective cohort study.
Use of serum C reactive protein and procalcitonin concentrations in addition to symptoms and signs to predict pneumonia in patients presenting to primary care with acute cough: Diagnostic study.
POCT can be defined as the process of indicating, executing, processing, interpreting, documenting, reporting, and following up of a laboratory test by a skilled and competent health care professional in proximity of the patient.
In primary care, CRP POCT is a proven cost-effective tool for reducing antibiotic prescribing for patients with suspected LRTIs, including acute exacerbations of chronic obstructive pulmonary disease. However, evidence for its (cost)-effectiveness in the NH setting is yet lacking.
Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: Cluster randomised trial.
C-reactive protein point of care testing and physician communication skills training for lower respiratory tract infections in general practice: Economic evaluation of a cluster randomized trial.
Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: A multinational, cluster, randomised, factorial, controlled trial.
We examined the effect of CRP POCT on antibiotic prescribing for NH residents with suspected LRTI in a cluster randomized, controlled trial (the UPCARE study: “Using Point-of-care C-reactive protein to guide Antibiotic prescribing for Respiratory tract infections in Elderly nursing home residents”). A full description of the UPCARE study design is given elsewhere.
Using point-of-care C-reactive protein to guide antibiotic prescribing for lower respiratory tract infections in elderly nursing home residents (UPCARE): Study design of a cluster randomized controlled trial.
The implementation and use of a new intervention in NHs can be challenging, given the heterogeneity of the population and the complexity of the setting.
The implementation process of CRP POCT in the UPCARE study required a collaborative approach between the NH, research team, and a primary care laboratory (hereafter referred to as laboratory), to tailor implementation aspects to organizational practices. A process evaluation of this intervention may help to obtain insight into the internal and external validity of the intervention. Also, findings help to increase our understanding of the magnitude and direction of effect of the intervention and its implications.
The aim of this process evaluation is (1) to determine intervention quality regarding CRP POCT utilization in the UPCARE study, and (2) to determine barriers and facilitators for the implementation and utilization of CRP POCT in the NH setting.
Methods
This mixed-methods process evaluation is part of the UPCARE study and was conducted around the end stage of the UPCARE trial (ie, March through July 2020).
Trial Design
The process evaluation was conducted alongside a cluster randomized, controlled trial. This trial was performed in 11 NHs across the Netherlands, of which 6 were randomized to the intervention group and 5 to the control group. The study population comprised NH residents of psychogeriatric, somatic, geriatric rehabilitation, and short-term residential care wards, who were suspected of having LRTIs. Physicians in the intervention group had access to CRP POCT for NH residents they suspected of having LRTIs. The control group was provided usual care without the use of CRP POCT. Physicians filled out information for participants on clinical status, diagnostic work-up, and management in electronic case report forms at 3 time points: at initial consultation, and 1 week and 3 weeks later. The primary outcome measure was antibiotic prescribing at initial consultation and secondary outcome measures involved clinical outcomes during follow-up.
Intervention Description
In Table 1 we summarize the various elements of the CRP POCT process and corresponding intervention components. Our study protocol article
Using point-of-care C-reactive protein to guide antibiotic prescribing for lower respiratory tract infections in elderly nursing home residents (UPCARE): Study design of a cluster randomized controlled trial.
provides a more detailed description of intervention components, such as medical and technical POCT training sessions. The medical training session aimed to provide intervention group physicians with sufficient knowledge on correct utilization of CRP POCT, based on literature and the current Dutch LRTI NH guideline.
The 2 main aspects of this training were patient selection for CRP POCT (ie, in case of clinical ambiguity and potential for therapeutic consequences) and interpretation of results (eg, cut-off CRP-values for management decisions). Throughout the trial, newly employed physicians received the medical training information via our instruction materials, additional training sessions, or from colleagues. The laboratory provided a technical training session for potential users of CRP POCT. For CRP POCT-user group selection (nurses and/or physicians), we asked NHs to balance full shift coverage (ie, including out-of-hours shifts) and minimal group size to ensure frequent POCT utilization over time. Among training participants, an in-house POCT-trainer was appointed for the NH to expand the POCT-user group if necessary. The instructors provided instruction manuals to be kept next to the POCT-analyzer.
Table 1CRP POCT Process and Corresponding Intervention Components
CRP POCT Process Component
Description
Corresponding Intervention Components
Patient selection
Appropriate patient selection for CRP POCT by treating physician
Medical training session
Execution
A skilled physician/nurse obtains a finger prick blood sample and handles further sample preparations. Materials are stored as per guidelines.
Technical POCT training session; logistics and quality assurance.
Processing
The skilled physician/nurse performs the measurement with the POCT instrument within 2 h after blood sampling.
Technical POCT training session; logistics and quality assurance.
Documentation
If different NH employees involved: the skilled physician/nurse who performed the measurement communicates the CRP-value to the treating physician. The treating physician documents the CRP-value in the electronic health record.
Logistics and quality assurance
Interpretation
The treating physician interprets the CRP-value alongside clinical signs and symptoms and decides on (antibiotic) management accordingly.
Medical training session
Reporting
The treating physician communicates management decisions to relevant parties involved as per usual care.
N/A
Follow-up
The treating physician monitors clinical status and uses CRP POCT for follow-up if necessary.
The POCT-analyzer was placed in or near the office of the POCT-user group, or in another type of staff room that allowed the POCT-analyzer to be near the fridge-stored test materials. In general, the blood sample was collected at the resident's room by the POCT-user. Then, the sample was dispensed in the buffer solution in the cuvette, which was then closed off with a reagent cap and transported to the analyzer for further processing. The test could be performed when the cuvette was warmed up to room temperature and within a maximum of 2 hours. The POCT-analyzer Quikread go (Aidian Oy, Espoo, Finland) was shown to have adequate analytical performance compared with laboratory assessment.
The added diagnostic value of five different C-reactive protein point-of-care test devices in detecting pneumonia in primary care: A nested case-control study.
The laboratory is compliant with the ISO Norm 15189 (M037) and recommendations for POCT, and verified each POCT-analyzer before transport to the NH site. The laboratory also continued quality assurance with periodic quality control visits of the POCT-analyzer at each site.
Process Evaluation
We evaluated process data related to intervention quality
(ie, logistics and experiences regarding CRP POCT in the UPCARE trial). For insight into implementation knowledge, we assessed barriers and facilitators for the implementation and utilization of CRP POCT.
Intervention Quality
We assessed intervention quality by evaluating experiences of involved NH employees regarding CRP POCT satisfaction, relevance, and feasibility in the NH setting during the trial. Another parameter of intervention quality was fidelity, which concerns the degree to which the intervention was delivered as intended.
Besides process description, data sources were the following: trial data (on illness severity), trial monitoring reports, logs of communication with NHs and the laboratory, POCT-analyzer records (last 100 measurements per POCT-analyzer), and a process evaluation questionnaire completed by physicians and nurses of intervention NHs (hereafter “questionnaire”).
POCT-analyzer records were retrieved within 1 month after trial conclusion and comprised pseudonymized user level information (ie, users filled out their initials). An estimation of the number of users per organization and location was made based on initials. POCT-analyzer records were used to show the use of CRP POCT over time.
The questionnaire comprised questions on CRP POCT utilization and appraisal. Most of the questions were close-ended and included a score option between 1 (totally disagree) and 10 (totally agree). Questions on satisfaction and relevance included the medical and technical POCT training sessions, experienced capability of using and interpreting CRP POCT, the added value and influence of CRP POCT on management decisions, and user-friendliness of CRP POCT. Questions regarding feasibility concerned the use of guideline-specified cut-off CRP-values, accessibility of CRP POCT (materials), and experienced feasibility of CRP POCT within the timeframe of initial consultation and during nights and weekends. Questions concerning fidelity included training attendance, patient selection, and the utilization of CRP POCT.
Descriptive statistics of POCT-analyzer records and the questionnaire were obtained using Microsoft Excel 2016 and SPSS statistical software v 26 (IBM Corp).
Implementation Knowledge
Focus group meetings took place in June and July 2020 with physicians and nurses of 3 intervention NHs. A purposive sampling method was used to select organizations based on variation in inclusion rate during the trial (low, medium, and high), ward sizes (psychogeriatric, somatic, and geriatric rehabilitation), and physician turnover (high-low). The meetings were held using a semistructured topic list and were led by a moderator. All focus group participants were asked for informed consent and approval of audio recording of the focus group by the researchers.
The topic list was developed by the researchers and comprised 2 domains: implementation and utilization. Implementation topics included experiences with the medical and technical POCT training sessions and organizational culture regarding innovation. Utilization topics regarded experiences with CRP POCT processes and patient selection, and the added value and influence of CRP POCT in management decisions.
Audio recordings were transcribed verbatim. Data analysis consisted of open coding performed by 2 researchers independently (T.B. and M.E.), and axial and selective coding performed by 1 researcher and reviewed by 2 other researchers (T.B., F.S., and L.B.). The software program Atlas.ti v 8 was used. During open coding, the researchers (T.B., F.S., and L.B.) coded relevant fragments of each transcript individually and discussed codes after each transcript for consensus. During axial coding hierarchical connections were made between categories through discussion between the researchers (T.B., F.S., and L.B.) about the open codes. During selective coding, data were further structured and researchers reflected on relations between themes and categories. If relevant, themes and categories were presented in a conceptual framework.
Results
Intervention Quality
Fidelity
Rate of staff involvement
The average attendance rate of all physicians per NH organization to the medical training session prior to trial commencement was 39% (range 15%–92%). An optional quiz regarding the medical training session was filled out on average by 32% (10%–60%) of all physicians per organization, irrespective of training attendance. The average quiz score per organization was 66% (40%–92%) correct. During the trial, 4 of the 6 intervention NHs received an extra medical training session 1 or 2 times for new employees or as a refresher. Two NHs arranged for training of new physicians themselves using our instructions. Among questionnaire respondents, 14% did not receive the medical training information in any form.
On average 7 (range 4–11) NH employees participated in the technical CRP POCT training sessions. Each organization appointed 2–4 employees as in-house POCT-trainer. According to available data, in-house POCT-trainers from 2 NHs trained additional (11 respectively 13) employees shortly after the training. The run-in period was on average 7 weeks (range 2–12 weeks). At the end of the run-in period, the ratio of POCT-users to the number of residents per location (or organization, as appropriate) was on average 1:26 (range 1:4–1:61). We do not have information regarding newly trained employees during the trial. Of the 21 questionnaire respondents who were trained for CRP POCT, 18 received the training from the laboratory and 3 from a colleague.
POCT-analyzer records showed on average 27 users per organization (range 15–45), with an average of 5 (range 2–12) measurements per user. Employees who were trained before the start of the trial performed 48% (range 20%–79%) of all measurements per organization. The proportion of users who performed ≤5 measurements per organization was on average 71% (range 37%–89%).
Patient selection
Among the 25 questionnaire respondents who used CRP POCT, 5 respondents used CRP POCT for “not ill” patients (according to subjective clinical judgement
), all used CRP POCT for patients who were moderately ill, and 11 respondents used CRP POCT for patients who were severely ill. This finding corresponded with CRP POCT utilization primarily for trial participants who were moderately ill: 78% of CRP POC-tested participants were moderately ill, 16% were not ill, and 7% were severely ill.
CRP POCT utilization
According to the analyzer records, CRP POCT was on average across NHs most often used during office hours (87%, range 68%–96%) and less frequently during nights (7%, range 1%–15%) or weekends (6%, range 2%–17%). One NH only utilized CRP POCT during office hours because they saw too little potential for CRP POCT to affect management decisions during their out-of-hours shifts. This NH remained content with this choice during the trial.
In Figure 1, the combined total use of CRP POCT is shown for all participating NHs, which shows use of CRP POCT during the run-in period and continued use during the trial. In general, a pattern of slightly increased use in winter months and a peak in July 2019 can be seen. A trough in CRP POCT use from April until July or August was more pronounced in some locations (data not shown). For 3 of total 18 locations measurements prior to the last 100 measurements were missing due to device memory capacity. The imputed data based on supply orders for this period show that these 3 locations performed a large portion of measurements in the total of measurements. The average use per device during the trial was on average 3.1 times per month (range 0.2–9.6). We do not have information on the proportion of tests that resulted in error messages, which either required to retest the sample or to collect a new sample. Among questionnaire respondents, POCT-users indicated that their workflow in case of an error message was to use a new sample (n = 3), to retest the sample or use a new sample depending on the type of error (n = 3), or to repeat the test (ie, unspecified for resampling or retesting the sample, n = 2).
Fig. 1Combined total use of CRP POCT among all participating intervention group NHs. For 3 locations of in total 2 NHs, data is missing before Q3 2019 (n = 2) and Q1 2019 (n = 1). An estimation for this missing data is made by averaging the order quantity between order dates and adding it to the total number of measurements.
Supplementary Table 1 shows the mean agreement scores of respondents regarding statements of CRP POCT relevance, feasibility, and satisfaction. Respondents scored on average >7 regarding questions on satisfaction with training sessions and user-friendliness of the analyzer. Respondents who received the medical training from a colleague or via instruction materials in absence of a live session were less satisfied with the method (score: 6.6) and content (score: 6.4). Each agreement score was on average >8 regarding questions of added value and trust regarding CRP POCT, and use and usefulness of cut-off values for management decisions. Supplementary Table 3 shows that >20 of 25 respondents believed CRP POCT utilization to be feasible at initial consultation, weekends, and nights. Of the 6 NH organizations in the intervention group, all wished to continue CRP POCT in all or some of their locations, and 1 immediately continued CRP POCT in 1 of their locations after the trial had ended.
Appendix 1 further elaborates on intervention quality aspects, and also on focus group findings regarding CRP POCT utilization. Main focus group findings regarding CRP POCT implementation knowledge are provided below.
Implementation Knowledge
Figure 2 depicts the conceptual framework we developed based on identified subthemes and factors. Most factors can be considered both facilitator and barrier (ie, if not well established, a factor can be considered a barrier). Central barriers/facilitators were getting people on board, creating initial momentum, continued attention/enthusiasm, routine practice, and trust. A willingness to change practice and broad recognition of importance helped getting NH staff on board. This broad support was perceived necessary for the required changes and time investment. Besides getting the people on board who will be directly involved with CRP POCT, support on the management level was also mentioned. Management was perceived to facilitate implementation if they were at least neutral toward this innovation and if the involved staff were allowed room for innovation.
Fig. 2Conceptual framework of barriers and facilitators for CRP POCT implementation in the NH setting.
The nature and demandingness of innovation was related to getting people on board as well as to creating initial momentum. The nature of innovation was considered comparable to other NH innovations, which facilitated implementation. Also, few barriers to implementation were experienced because of perceived low demand and temporality of innovation (ie, for the duration of the trial). Conversely, the complexity of test procedures was perceived as an initial threshold. However, this threshold was considered inherent to innovation and important to get past for achieving skilled and consequently routine practice. Enabling factors were a positive first experience, a short time between training and first experience, and the instruction manual.
Physician 1: “Well, for all new things you have to just get past some sort of barrier, I shall say. We were properly instructed how to go about it, but it took a few weeks before I saw my first patient. However, all, I, the instruction manual was very clear. And then it was actually fun to do.”
Process facilitators in the relation between continued attention/enthusiasm and routine practice were proximity, 24/7 coverage, internal task division, and role of external partners. Close proximity (between personnel as well as to the POCT-analyzer) and well-defined roles facilitated the process in case different personnel performed the measurement respectively were involved with patient selection and follow-up. A perception regarding internal task division was that the nurse should be able to suggest doing POCT but the decision should lie with the physician. Furthermore, organizational and technical support from the laboratory, and nudges and incentives from the research team appeared to facilitate continued attention/enthusiasm and routine practice.
Nurse 1: “We did suggest the physicians, do you want to test for CRP? Ehm, and the physicians said do you want to test for CRP. You know, if you actively draw each other's attention to it then it happens more often, and that is what happened less in location 2.” […] Nurse 2: “I think it maybe also relates to, nurse 1 and 3, that physicians are also in your office, and then you can just talk about it, and then it is, the lines of communication are shorter, compared to when you have to track each other down.”
Lastly, a process factor positioning of CRP POCT within current practices was brought into context of routine practice and trust. Focus group participants seemed to experience fewer barriers to measuring CRP via POCT compared with send-out laboratory measurement, in terms of shorter time-to-results, improved reach of smaller locations, night-/weekend-shift coverage, and in-house management.
Physician 2: “Yes, well, look, at ehmm. the lab visits smaller locations 1 to 2 times a week. And then you have to pretty well move heaven and earth to ehh to, to get a CRP. And the results are also sometimes difficult to track down; I have to say, in practice. So the lines of communication are very short if you do have point-of-care.”
Conversely, for NHs that customarily use send-out laboratory rush orders, CRP POCT did not add value to current practice except for during nights or weekends. Furthermore, some NH employees expressed less trust toward CRP POCT because of experienced deviations of POCT from laboratory measurements. These deviations were cautiously related to the extent of skilled measurement, which underlines the importance of adequate training for routine practice and trust.
Factors identified within the subtheme implementation contents involved experiences with instructions, practice, instruction tools, recollection, POCT-user group, and training of new employees, which could be related to the process factors from initial momentum to trust. Physicians considered all training instructions satisfyingly clear, but expressed the wish for conciseness in general. Practicing on each other was perceived as a good training method and necessary investment to obtain skilled practice. Practicing required many materials but also revealed technical difficulties, which made POCT-users aware of their initial underestimation of required skills. The instruction manual emerged as an important tool as recollection decreased with a longer time before seeing the first patient.
Physician 3: “My name is XX, elderly care physician, and I have some experience with it [CRP POCT]. A couple of times I could delegate it. When I had to do it myself one time, I had to rediscover for a moment how to go about it, because there are actually many steps in the test procedure, and materials that are in the fridge and those that are not in the fridge, so it was nice to have a good instruction manual. But you did need to take the time and ease to do it [for the first time].”
Success factors for POCT-user group selection were group diversity, manageable group size and holding on to this. The largest role was ascribed to practice nurses during office hours and/or general nurses for achieving 24/7 coverage. A back-up role for physicians seemed sufficient in both cases. For instance, during nights or weekends, the physician sometimes performed POCT to relieve the workload of the out-of-hours chief nurse. Less oversight of the training of new employees was related to somewhat more unrestricted or unwarranted use of CRP POCT.
The training of new employees seemed organized well if the training was part of the general new employees onboarding process, or if it was a prerequisite for the use of CRP POCT. The training of the in-house POCT-trainer was perceived as satisfactory and clear, and the method of coaching was deemed suitable. Instances of less organized training methods were characterized by high staff turnover and coincided with a generally lower recollection of training and decreased attention/enthusiasm. Consequently, new physicians delegated or did not use POCT-measurement. Reportedly, the training of new employees could improve if physicians stimulate and frequently interact with the in-house POCT-trainer.
Discussion
The aim of this mixed-methods process evaluation was to assess the implementation and use of CRP POCT in NHs. We evaluated intervention quality, and assessed barriers and facilitators for the implementation and use of CRP POCT. This process evaluation showed sufficient intervention quality and together with implementation knowledge these findings provide clues and conditions for logistics of CRP POCT implementation in NHs. Trial results showed that access to CRP POCT reduced antibiotic prescribing for suspected LRTI and, therefore, support large-scale implementation.
Effect of C reactive protein point-of-care testing on antibiotic prescribing for lower respiratory tract infections in nursing home residents: Cluster randomized controlled trial.
The quality assessment indicates sufficient internal and external validity of the intervention. The medical training attendance was on average low, but training alternatives and public guideline availability offered compensation to attain required knowledge. Physicians did prefer a live session, which also served to build trust toward adjusting management decisions. In future implementation processes without external oversight, we recommend to appoint a team champion among physicians responsible for the medical training knowledge within the group. A team champion would also contribute to oversight of POCT-user group composition and training status. The technical training of new employees appeared well-organized with in-house POCT trainers. Also, questionnaire respondents felt capable in CRP POCT utilization. Yet, the increased group size during the trial and consequential infrequent use per POCT-user for some locations indicate superfluity in POCT-user group size, which could have affected routine practice.
Other parameters indicated adequate fidelity. Patient selection for CRP POCT generally corresponded with guideline recommendations and CRP POCT use continued over time. In general, lower CRP POCT use in smaller-sized NH locations (ie, <100 residents) coincided with a similarly low number of participants, therefore, we assume low LRTI incidence rather than insufficient CRP POCT implementation.
Barriers and Facilitators
Because the trial results support the benefit of large-scale implementation of CRP POCT, we provide recommendations (Figure 3) for future implementation processes based on barriers/facilitators identified in the current process evaluation.
Effect of C reactive protein point-of-care testing on antibiotic prescribing for lower respiratory tract infections in nursing home residents: Cluster randomized controlled trial.
A willingness to change practice and perceived added value of the innovation among staff similarly appeared as facilitators in other NH process evaluation studies with different types of interventions.
Qualitative study to explore the views of general practice staff on the use of point-of-care C reactive protein testing for the management of lower respiratory tract infections in routine general practice in England.
The perceived low-demanding nature of CRP POCT implementation seemed to improve initial commitment. Other NH process studies also describe this relation between demandingness of innovation and its uptake, which suggests a general point for consideration in implementation processes.
Qualitative study to explore the views of general practice staff on the use of point-of-care C reactive protein testing for the management of lower respiratory tract infections in routine general practice in England.
Likely, the demandingness of the innovation should be proportional to its perceived added value.
Facilitators for continued attention/enthusiasm and skilled routine practice were 24/7 coverage with a diverse and coordinated POCT-user group, and proximity, (ie, short lines of communication between personnel and short distance to the POCT-analyzer). This interaction between continued attention, proximity, and routine practice was also seen in another study.
Qualitative study to explore the views of general practice staff on the use of point-of-care C reactive protein testing for the management of lower respiratory tract infections in routine general practice in England.
POCT-users experienced the instruction manual as useful, especially in case of waned practice. Furthermore, other studies also describe staff turnover as a barrier to group medical training knowledge.
Although communication logs indicated difficulty for some NHs to retain group knowledge in the face of high staff turnover, this was mentioned to a lesser extent in the focus group interviews. We recommend regular discussion of experiences with CRP POCT among staff as part of group knowledge building and for safeguarding continued attention.
Physicians agreed that patient selection for CRP POCT required the potential for therapeutic consequences. This finding concurs with guideline recommendations and other studies involving CRP POCT.
Qualitative study to explore the views of general practice staff on the use of point-of-care C reactive protein testing for the management of lower respiratory tract infections in routine general practice in England.
Qualitative study of primary care clinicians' views on point-of-care testing for C-reactive protein for acute respiratory tract infections in family medicine.
"A false sense of confidence" The perceived role of inflammatory point-of-care testing in managing urinary tract infections in Dutch nursing homes: A qualitative study.
Another perceived value of CRP POCT, however, was for prognostication and monitoring. As our trial was not designed for assessment of these purposes, possibly, future studies could focus on CRP-values related to prognosis and monitoring along the disease trajectory.
"A false sense of confidence" The perceived role of inflammatory point-of-care testing in managing urinary tract infections in Dutch nursing homes: A qualitative study.
Similar to other studies, physicians in this study believed that CRP POCT reinforced their diagnostic toolkit, while they were also cautious toward over-reliance.
"A false sense of confidence" The perceived role of inflammatory point-of-care testing in managing urinary tract infections in Dutch nursing homes: A qualitative study.
A strength of this process evaluation was the use of a mixed-methods design. Although the use of multiple data sources strengthened our findings, the questionnaire response rate was limited (33%). The use of focus group interviews enriched implementation knowledge regarding CRP POCT. Of note, because we evaluated in study context, certain factors need to be considered for implementation outside the research setting. As aforementioned, in the absence of external oversight from a research team, NHs could appoint a team champion and partner with a laboratory. Furthermore, this process evaluation precedes the current severe acute respiratory syndrome coronavirus 2 pandemic. Consequently, our findings do not consider the additional strain on health care personnel and doubtlessly increased difficulty for implementation processes.
Conclusions
This process evaluation showed sufficient quality of providing CRP POCT in Dutch NHs. We processed findings of intervention quality and implementation knowledge into key recommendations for CRP POCT implementation in this setting, such as short distances and short lines of communication. Future research could focus on CRP POCT use (eg, logistics and role in management decisions) in countries with different organization of care in NHs, for instance, without in-house physicians or with different practices regarding hospital referrals.
Acknowledgments
We thank the physicians and nurses from nursing homes participating in the UPCARE trial who responded to our questionnaire and who participated in our focus group interviews. We thank the research team member Melissa van Essen for her contribution to the data collection and first part of open coding of focus group interviews. We thank Jochen Cals and Ruth Veenhuizen for their contribution to the conception and initial design of the UPCARE study. We also thank Saltro diagnostic center location Utrecht for their collaboration and quality control oversight of CRP POCT-use during the trial. The funding bodies had no role in the design of the study, data collection, data analysis, interpretation, or in writing the manuscript or authority over any of these activities.
Supplementary Data.
Supplementary Table 1Experienced Relevance, Satisfaction, and Feasibility of CRP POCT in the NH Setting
Answers for the influence of the medical training session were omitted if the respondent indicated that he/she did not follow any kind of medical training for the UPCARE study.
15
4.6, 1–8
Participation in the UPCARE study in general
19
6.7, 2–9
Other influences
19
5.2, 1–9
∗ Respondents answered to the statement for each factor with an agreement score between 1 (totally disagree) – 10 (totally agree).
† Answers for the influence of the medical training session were omitted if the respondent indicated that he/she did not follow any kind of medical training for the UPCARE study.
This appendix provides supplementary results regarding intervention quality and implementation knowledge.
Intervention Quality
Satisfaction, relevance, and feasibility
Satisfaction scores were on average between 7 and 8 (on a 10-point scale) for methods and content of the POCT and medical training sessions (see Supplementary Table 1). Respondents who received the medical training from a colleague or via instruction materials in absence of a live session were less satisfied with the method (score: 6.6) and content (score: 6.4). Respondents felt to a certain extent capable in CRP POCT performance (score: 7.2) and interpretation (score: 7.6). Physicians often communicated that they perceive CRP POCT as a simple or normal procedure, analogous to glucose measurement and other measurements requiring a finger prick.
Respondents experienced added value of CRP POCT and trust in CRP POCT results for management decisions (scores: 8.5 respectively 8.2). Users scored 7.2 (range 3–10) when asked if CRP POCT had changed their management decisions. Supplementary Table 2 shows that respondents thought that the use of CRP POCT and the NH LRTI guideline influenced their antibiotic prescribing most (scores: 7.6 respectively 7.3) and the medical training session the least (score: 4.6). Other influences on prescribing decisions that were mentioned among questionnaire respondents were increased general attention for the issue of antimicrobial resistance (n = 4), medical specialist education or peer-review (n = 3), and the regular staff meetings regarding pharmacotherapy (n = 2).
Feasibility
Supplementary Table 3 shows that most (22 of 25) respondents felt like they had the time to use CRP POCT around initial consultation. Also, 20 of 25 respondents thought CRP POCT to be appropriate for nights or weekends. The POCT-analyzer, materials, and instructions were thought to be easily accessible (>80% of 27 respondents) and user-friendly (score: 7.8). Respondents who included participants indicated actual use and usefulness of LRTI guideline-proposed cut-off values in clinical practice (scores: 8.0 respectively 8.1).
Implementation Knowledge
Utilization of CRP POCT
General experiences with the use of CRP POCT were shared regarding patient selection for CRP POCT, measurement and evaluation of results.
Patient selection for CRP POCT
Views concurred with guideline recommendations with regard to patient selection, for instance, physicians thought that CRP POCT should only be used if there are potential therapeutic consequences. Differing views appeared for patient selection among psychogeriatric patients. Some physicians experienced no differences in patient selection for POCT, while others experienced differences in infection recognition among psychogeriatric compared to somatic patients. The patient's understanding was viewed as a barrier for performing POCT, but the finger prick was perceived not to be more burdensome. Broad laboratory assessment was preferred over CRP POCT for severely ill patients receiving empirical antibiotic treatment.
Measurement
The POCT-analyzer was experienced as clear, user-friendly, quick, and pleasant. The instructions were thought to be straight forward; however, the number of test procedure steps and required technical skills necessitated sufficient practice and the use of the instruction manual. The finger prick measurement was thought to be similar to other tests such as blood glucose measurement. Lastly, a desired improvement of a POCT such as for CRP was the ability to differentiate between viral and bacterial causes.
Evaluation
Short lines of communication facilitated retrieval of CRP POCT results for evaluation. Doubts were raised about telephone communication of results to out-of-hours service physicians without them seeing the patient. In that case, CRP POCT might unjustifiably have more weight in treatment decisions.
The guideline-specified cut-off values for CRP in the treatment decision were perceived as adequate. A side note was made that the guideline should leave room for individual variation. CRP-values were in instances unexpected, either surprisingly low or high. Most often the CRP-value was surprisingly low, which justified the choice for no antibiotics and eased the choice for watchful waiting.
The role of CRP POCT in treatment decisions was described in varying degrees. Instances of larger dependency were described as support for not prescribing antibiotics, a confirmation of gut feeling, or differentiation of infection in case of unclear disease focus. Also, CRP POCT was found useful for clear and quick guidance on (short-term) management, specifically in initial phases of disease. In case of lower dependency, a greater importance was ascribed to the clinical signs and symptoms, along which CRP merely offers a small and indirect course of direction.
Physician 4: “And also, in my opinion, you of course have to give priority to your clinical impression […] you are treating a patient, not a number.”
Experienced effects of CRP POCT were a direct impact on antibiotic prescribing (ie, fewer), having a more justified management decision, an ease of mind, but also instances of limited effects on antibiotic prescribing. Trust in CRP POCT increased if spontaneous recovery was observed after withholding antibiotics.
Physician 5: “You do have something ‘extra’ [with CRP POCT], also sometimes it is reassuring to see that the CRP-level is low. Then you do sleep better, I shall say.”
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This work was supported The Netherlands Organization for Health Research and Development (ZonMw, program Antibiotic Resistance, grant number 541001 004).
LB reports a grant from The Netherlands Organization for Health Research and Development (ZonMw, program Antibiotic Resistance, grant number 541001 004), for the conduct of the current study. TB, FS, CH, RH and MT have no competing interests to disclose. TV reports grants from Abbott, Becton Dickinson, Biomerieux, European Commission, grants from European Commission, Orion, during the conduct of the study; grants from European Commission, Janssen Pharmaceuticals, grants from ZonMw, outside the submitted work. The Medical Ethical Committee of the VU University medical center in Amsterdam approved the trial protocol on March 28, 2018, as well as participation of all recruitment sites (NHs) in the trial. The trial was registered at the Netherlands Trial Register on 29 August 2018 with trial number NL5054. Orion Diagnostica and Saltro made in total 20 CRP POCT instruments available for the study.
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