BACKGROUND: Implementation of primary care models involving expanded scope of work and redesigned workflows for medical assistants (MAs) as primary care team members can be challenging. Implementation strategies and participatory evaluation informed by implementation science frameworks may inform organizational decisions about model scale-up and sustainment. OBJECTIVE: This paper reports implementation strategies and qualitative evaluation of a primary care redesign (PCR) model implementation that included an expanded scope of work for MAs. DESIGN: Qualitative evaluation of implementation strategies and clinician and staff experience with implementation of PCR using semi-structured key informant interviews. The evaluation was guided by the RE-AIM framework and the Consolidated Framework for Implementation Research. PARTICIPANTS: Sixty-nine clinicians, staff, practice leaders, and administrators from 7 primary care practices (4 general internal medicine, 3 family medicine) implementing PCR. INTERVENTIONS:The PCR model included enhanced rooming and documentation support. The health system used multiple strategies to implement PCR, including rapid improvement events, changing clinic space configurations, developing electronic health record templates and performance dashboards, and practice coaching. APPROACH: The Consolidated Framework for Implementation Research and the RE-AIM evaluation and planning framework guided development of semi-structured interview guides. A deductive, structural coding approach was used for analysis. KEY RESULTS: PCR implementation was facilitated by clear communication about the intervention source, mechanisms for feedback about model goals, and physical environments and electronic health record (EHR) systems that supported the added staff and modified clinic workflow. Clinicians and staff benefited from the ability to see the model in action prior to go-live and opportunities for consistent provider-MA pairings. CONCLUSIONS: The PCR model can support achieving the Quadruple Aim when fully implemented with paired MAs and clinicians who are well prepared to follow redesigned workflows and function as a team. Implementation can be effectively supported by a participatory evaluation guided by implementation science frameworks.
Introduction Inhalation injury is associated with increased incidence of pneumonia. Bacteria are commonly isolated from bronchoalveolar lavage (BAL) within 12-48 hours of injury with unclear clinical significance. We aimed to determine if grade of inhalation injury is associated with different bacterial species isolated from initial BAL, and if higher inhalation injury grade is associated with increased risk of pneumonia. Methods Abbreviated injury scores (AIS) and clinical microbiology isolates from diagnostic bronchoscopy with BAL performed within 48 hours of injury among adults with inhalation injuries from 2009-2022 were extracted from medical records at an ABA-verified burn center. CDC PNU1 criteria was used to identify pneumonia >48 hours after admission. Modified Poisson regression with robust standard errors was used to assess the association of inhalation injury grade and subsequent pneumonia. Results Two hundred forty-six patients with inhalation injury who underwent diagnostic bronchoscopy for airway inspection and surveillance BAL within 48 hours of injury were included in this analysis. Fourteen (5.7%) were grade 0, 106 (43.1%) grade 1, 75 (30.5%) grade 2, 51 (20.7%) grade 3-4. The most common bacterial isolate was Streptococcus spp irrespective of AIS grade. Higher AIS grade was associated with increased incidence of pneumonia (IRR 1.3; 95% CI 1.09-1.61; p = 0.01) after adjustment for age, sex, and total body surface area of burn involvement. Conclusions Bacterial species isolated did not differ by inhalation injury grade. Higher inhalation injury grade was associated with increased risk of pneumonia. Applicability of Research to Practice Providers should be vigilant that patients with higher grade of inhalation injury are at increased risk of pneumonia. Further research is urgently needed to assess the clinical significance of organisms isolated on initial BAL and their role – if any – on the development of pneumonia.
Introduction Inhalation injury is associated with increased risk of pneumonia. Bronchoscopy with bronchoalveolar lavage (BAL) is commonly used to diagnose and grade inhalation injury while obtaining a microbiological sample. It has been shown that a quarter of patients with inhalation injury have a single bacteria isolated from initial BAL within 12-48 hours of injury. The clinical significance of this and role of antibiotics in this setting are unknown. We investigated the incidence that bacteria isolated during a pneumonia episode were previously isolated on surveillance BAL among patients with inhalation injury. Methods Among patients with inhalation injury admitted to a large ABA-verified burn center from 2009-2022, microbiological isolates from initial BAL and subsequent culture obtained during a pneumonia episode (BAL, sputum), were extracted from medical records. Abbreviated injury severity score (AIS) was used to grade inhalation injury. Hospital-acquired pneumonia (HAP) was defined using CDC PNU1 criteria, and ventilator-associated pneumonia (VAP) was defined using PNU2 criteria with BAL cutoff >10,000 colony forming units (CFU). Results Two-hundred forty-eight patients with inhalation injury who underwent bronchoscopy for airway inspection and surveillance BAL within 48 hours of injury were included in the analysis. Of the 111 who had a bacterial isolate from initial BAL, 23 (21%) subsequently developed HAP or VAP during the hospitalization. Median (IQR) days between bronchoscopy and pneumonia diagnosis was six (2-8.5). In three of the 11 VAP cases (27%), the organisms identified at pneumonia diagnosis matched the organisms identified on initial BAL. Antibiotic use on admission was not associated with re-culture of initial BAL organism during a subsequent pneumonia episode (p=0.071). Conclusions Among patients with inhalation injury and bacteria isolated on surveillance BAL, 21% developed pneumonia during their hospital stay, usually with different bacteria than those isolated at initial bronchoscopy. There was no association between empiric antibiotic use and incidence of initial BAL organisms re-cultured during subsequent pneumonia episode. Applicability of Research to Practice Findings suggest initial BAL isolates cannot guide empiric coverage of pneumonia for patients with inhalation injury. This remains an important area of future research.
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