Discussion
®, HA-CDI
We created a multifaceted barrier-targeted intervention strategy to implement the Prevent CDI-55 + study across four adult hospitals in Calgary, Canada. Specifically, we conducted focus groups with front-line staff during the Prevent CDI-55 + study to identify ongoing barriers and facilitators for probiotic implementation. This information was then used to adapt the multifaceted intervention strategy accordingly.We found the most commonly discussed barriers to Bio-K + ® implementation were related to the process of prescribing the probiotic, intervention characteristics including administration of Bio-K + ® and post-discharge compliance, along with knowledge relating to probiotic effectiveness for preventing HA-CDI and knowledge regarding Prevent CDI-55 + . Based on the identified barriers, we specifically modified the prescribing alert for Bio-K + ® in the electronic order entry system, updated nurse education with regards to the administration of Bio-K + ®, and ensured patients were aware of how to access Bio-K + ® after discharge from hospital. We also utilized multi-component targeted education strategies throughout the implementation phase at each site.Previous studies that have evaluated the use of probiotics to prevent HA-CDI have reported low adherence to their respective study protocols. For example, a study by Trick and colleagues reported that only 26% of eligible patients received a probiotic in their study that was conducted in a 694-bed teaching hospital in Chicago, USA [To our knowledge, this is the first study to evaluate barriers and facilitators related to the implementation of probiotics in a real-world effectiveness study. Conducting the focus groups throughout implementation allowed participants to have some prior exposure to the study and associated probiotic, better informing their responses related to implementation barriers and facilitators. In addition, feedback from the focus group participants during the Prevent CDI-55 + study allowed the study team to adapt the multifaceted implementation strategy to address identified ongoing barriers at each site. Lastly, the large number of partners engaged in the Prevent CDI-55 + study, and the many educational sessions conducted allowed us to reach staff on a regular basis to ensure identified barriers were addressed.Our study is not without limitations. Specifically, there were barriers identified by participants that we were unable to address during the study, such as the concerns around adherence to Bio-K + ® after a patient was discharged from hospital. Although patient education was adapted to provide a list of pharmacies that carried Bio-K + ® at the time of discharge, the proportion of patients who completed the full course of Bio-K + ® post-discharge may have been low. Lastly, while only the general results of the adherence analysis are available in the Prevent CDI-55 + study, we did not examine the impact of each component of the multifactorial implementation strategy, or changes in the strategy over time, on adherence. This was due to the complexity of the stepped-wedge study design for the overall Prevent CDI-55 + study, limiting the ability to assess the change in the implementation strategy over time. However, we still note that the overall adherence to probiotic prescribing in the Prevent CDI-55 + study (76.9% to 84.6%) is numerically higher than the reported adherence to probiotics in previous hospital-based studies, ranging from 26 to 44% [