Enhancing Patient Safety by Preventing Urinary Tract Infection in Post-Acute Care

摘要 目前有超过140万人居住在美国养老院（NH），每年有200万新入院者。 NHS对于满足老年人的短期和长期护理需求至关重要。随着急性后 护理人群中，这些人中的许多人正在从严重事件中恢复，并且处于高风险 并发症，包括与医疗保健相关的感染。事实上，近25%的急性期后人群 返回医院感染，占325，000医院转移和超过40亿美元， 因此，健全的预防计划对于 预防感染，减少不必要的抗菌药物使用，减少耐多药菌的传播 微生物，并提高患者的安全性。然而，国家卫生机构在实施有效的 感染预防计划，包括有限的资源，诊断的挑战，在一个虚弱的功能障碍 长期居住的人口，以及令人无法接受的高流行率的多重耐药生物体。的模型 将NH感染预防计划与医院感染预防计划相结合， 负责任的护理组织框架有可能提高护理的连续性和质量， 感染、不适当的转移和抗生素耐药性的传播。通过这一提议，我们的目标是 首先使用3个医疗保健系统（包括3家大医院和15家 以社区为基础的NHS。然后，使用逐步楔形分组随机试验设计，我们建议检验 综合性尿路感染预防计划在减少导管相关和非导管相关尿路感染中的有效性 相关UTI，无症状菌尿患者抗生素使用不当，以及UTI相关 住院治疗我们将通过以下目标实现这些目标。具体目标1：制定 使用UTI（导管和非导管相关）预防医院和NH感染的综合模式 预防和管理作为范例，并在15个国家卫生机构和3个转诊医院试点这一模式。我们将 调整现有工具、材料、资源并最终确定研究方案。我们将特别强调有针对性 与无症状菌尿有关的合作和知识转让，使用诊断检测， 检测感染，使用标准化标准定义UTI，以及治疗决策。具体目标2：使用 阶梯楔形群随机试验设计，我们将测试一个综合感染预防模型， 在60个国家卫生机构预防所有导管和非导管相关尿路感染。具体目标2a：评估供应商和 领导层对综合感染预防模型的满意度，采用定性和定量方法 方法.具体目标2b：评价综合感染预防模式对其他NHSN的影响 可报告的结果和过程度量（例如，耐甲氧西林葡萄球菌培养阳性 金黄色葡萄球菌（MRSA）、艰难梭菌和其他耐抗生素微生物;手部卫生、手套和 长袍粘附）。

ABSTRACT Over 1.4 million people currently reside in a U.S. nursing home (NH) with 2 million new admissions each year. NHs are crucial for meeting short and long-term care needs of older adults. With the burgeoning post-acute care population, many of these individuals are recovering from serious events and are at high risk of complications, including healthcare-associated infections. In fact, nearly 25% of the post-acute population returns to a hospital with an infection, accounting for 325,000 hospital transfers and over $4 billion in additional healthcare costs per year in the U.S. Robust prevention programs in NHs are therefore critical to prevent infections, reduce unnecessary antimicrobial use, reduce transmission of multidrug-resistant organisms, and enhance patient safety. However, NHs face special challenges in implementing an effective infection prevention program, including limited resources, diagnostic challenges in a frail functionally disabled long-stay population, and an unacceptably high prevalence of multidrug-resistant organisms. A model that integrates NH infection prevention initiatives with hospital infection prevention programs within an Accountable Care Organization framework has the potential to improve continuity and quality of care, reduce infection, inappropriate transfers, and the spread of antimicrobial resistance. With this proposal, our goals are to first develop and evaluate an integrated model using 3 healthcare systems including 3 major hospitals and 15 community-based NHs. Then, using a stepped-wedge cluster randomized trial design, we propose to test the effectiveness of an integrated UTI prevention program in reducing catheter-associated and non-catheter- associated UTIs, inappropriate antibiotic use in patients with asymptomatic bacteriuria, and UTI-related hospitalizations. We will achieve these goals through the following aims. Specific Aim 1: Develop an integrated model of hospital and NH infection prevention using UTI (catheter and non-catheter-associated) prevention and management as an exemplar, and pilot this model in 15 NHs and 3 referral hospitals. We will adapt existing tools, materials, resources and finalize study protocols. In particular, we will emphasize targeted collaborations and knowledge transfer pertaining to asymptomatic bacteriuria, use of diagnostic testing to detect infection, defining UTI using standardized criteria, and treatment decisions. Specific Aim 2: Using a stepped-wedge cluster randomized trial design, we will test an integrated infection prevention model in preventing all catheter and non-catheter-associated UTIs in 60 NHs. Specific Aim 2a: Evaluate provider and leadership satisfaction with the integrated infection prevention model, using qualitative and quantitative methods. Specific Aim 2b: Evaluate the impact of the integrated infection prevention model on other NHSN reportable outcomes and process measures (e.g., positive cultures for methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, and other antimicrobial-resistant organisms; hand hygiene, glove and gown adherence).