Spotlight: KL2 Scholar Elizabeth Monsees, Ph.D.

KL2 Scholar: Elizabeth Monsees, Ph.D., RN, CIC, AL-CIP, FAAN, Children’s Mercy

Project Title: STRIDE: Streptococcus Testing Reduction Interventions through Diagnostic Excellence

Project Summary: Pharyngitis is a common reason for urgent care (UC) visits, usually viral not requiring antibiotics. Despite guidelines, testing for the bacteria, Group A Streptococcus (GAS), is often performed inappropriately. The overall goal of this research is to improve GAS testing by identifying salient implementation strategies in collaboration with an interdisciplinary team to address practice challenges to guideline-concordant testing.

Mentor(s): Brian Lee, MPH, Ph.D., Anne Sales, Ph.D., RN, FAAN, Emily Cramer, Ph.D., with clinical advisors, Rana El Feghaly, M.D., MSCI, CPHQ, and Amanda Nedved, M.D.

Elizabeth Monsees, Ph.D., RN, started her career as a neonatal nurse, but she has always been interested in infectious diseases. While working as a neonatal nurse, a baby died from gram-negative sepsis (a life-threatening, systemic inflammatory response to infection by gram-negative bacteria), and that sparked an interest in learning how to prevent infections in others.

With that in mind, she met an infection prevention nurse at Children’s Mercy who connected her with a colleague seeking an infection prevention nurse at a small community hospital.

“When I was working at that hospital, I managed a number of Clostridioides difficile (C diff) outbreaks, so we had to develop a number of prevention strategies, one of which was evaluating antibiotic use,” said Monsees, who is a nurse research scientist. “At that time, there were no formal antibiotic stewardship programs, and we did not have resources to conduct antibiotic reviews. While we were able to address the outbreaks, it was those outbreaks that led me to my research interest in antibiotic stewardship and this KL2 project. Five years later, when I joined Children’s Mercy, I led efforts on the influenza H1N1 pandemic and later transitioned into a clinical safety officer role.”

“In that role, I partnered with colleagues to formalize measures to evaluate serious safety events, conduct cause analyses, establish a staff support program and develop an error prevention educational program.”

This role led Monsees to pursue her Ph.D., and during this time she met a nurse researcher and infection preventionist at another institution who encouraged her to think about studying nurse engagement in antibiotic stewardship for her doctoral work.

“This was a full circle moment for me because it took me back to those pivotal moments in my career as a nurse, caring for patients with sepsis, responding to outbreaks, developing strategies to mitigate risk, but now linking it to ways to formally engage, the largest discipline in healthcare, nurses, in antibiotic stewardship. Although nurses, in their day-to-day work, support medication and diagnostic safety processes, at that time, their role in antibiotic stewardship was unexplored,” she said.

As her career continued, she moved into a senior director role in infection prevention and stewardship integration at Children’s Mercy, where she used her knowledge of safety science to develop and refine the hospital’s healthcare epidemiology programs.

Monsees KL2 project, which is focused on Urgent Care settings, will concentrate on identifying determinants that drive appropriate GAS testing to inform the selection of strategies that will hopefully optimize guideline-concordant testing. Research to understand the upstream processes, such as diagnostic testing, that influence downstream antibiotic prescribing is needed to identify barriers to stewardship programs. Ambulatory environments account for ~90% of human antibiotic use, with 30% of those prescriptions deemed inappropriate. We know from experts in antibiotic stewardship that antibiotic-related harm events lead to tens of thousands of emergency room visits annually, disproportionately affecting children.

With her time in the KL2 program, Monsees would like to bridge the gap between her expertise in implementation practice and her need for formal training and mentored experience in implementation science. She will remain focused on her continued love of infectious diseases and patient safety.

“One thing we see right now is that a patient may come into an urgent care with a sore throat, and we will do a test, which oftentimes leads to an antibiotic prescription. But it could be a virus, or the patient may not meet clinical criteria for testing,” she said. “Children’s Mercy has been a leader in developing strategies to support clinicians in appropriate test use. This KL2 study will include identifying factors that influence testing processes and using team-based strategies to support testing appropriateness.”

The mixed methods approach includes qualitative and quantitative data on test selection, such as time of day or day of the week, caregiver requests, and seasonality. Monsees hopes that such information will help us understand the factors that support or hinder optimal testing.

As the Kl2 program kicks off for her, she is looking forward to developing her skills and learning more about mixed methods as she moves toward working more in implementation science.

One thing she is looking forward to in the KL2 program is establishing connections with other investigators to continue growing and contributing as a researcher.

“I really like learning from different groups of people, and having exposure to new thinking partners from new collaborations will allow me to look at testing and antibiotic use differently and learn new ways to reduce preventable harm,” she said.

Monsees hopes that her research can one day create a plan not only to identify antibiotic harm events but also to prevent them.

Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under the Award Number UL1TR002366.