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

摘要 目前有超过140万人居住在美国疗养院(NH)，每年有200万人新入院。 国民健康保险制度对于满足老年人的短期和长期护理需求至关重要。随着后急性肺炎的迅速发展 护理人群中，这些人中的许多人正在从严重事件中恢复，并处于患 并发症，包括与医疗保健相关的感染。事实上，近25%的后急性发作人口 因感染而返回医院，占32.5万次医院转院和超过40亿美元的 美国每年的额外医疗费用。因此，NHS强有力的预防计划对 预防感染，减少不必要的抗菌药使用，减少多重耐药的传播 微生物，并提高患者的安全。然而，NHS在实施有效的 感染预防计划，包括有限的资源，在虚弱的功能障碍中的诊断挑战 长期滞留人口，以及耐多药生物体的高得令人无法接受的流行率。这是一款 将NH感染预防措施与医院感染预防计划整合在 责任护理组织框架有可能改善护理的连续性和质量，减少 感染、不适当的转移和抗菌素耐药性的传播。通过这项提议，我们的目标是 首先开发和评估使用3个医疗保健系统的综合模型，包括3个主要医院和15个 以社区为基础的NHS。然后，使用阶梯楔形整群随机试验设计，我们建议检验 尿路感染综合预防计划在减少导管相关性和非导管相关性感染方面的有效性 相关的尿路感染，无症状菌尿患者的不适当抗生素使用，以及尿路感染相关 住院治疗。我们将通过以下目标实现这些目标。具体目标1：制定一项 使用尿路感染(导尿管和非导尿管)预防医院和NH感染的综合模式 预防和管理作为示范，并在15家NHS和3家转诊医院试行这一模式。我们会 调整现有的工具、材料、资源，并最终确定研究方案。我们将特别强调有针对性的 关于无症状性菌尿的合作和知识转让，使用诊断检测来 检测感染，使用标准化标准定义尿路感染，并做出治疗决定。具体目标2：使用 步进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 在60个NHS中预防所有导管和非导管相关性尿路感染。具体目标2a：评估提供者和 领导对综合感染预防模式的满意度，使用定性和定量 方法：研究方法。具体目标2b：评估综合感染预防模式对其他NHSN的影响 可报告的结果和过程措施(例如，耐甲氧西林葡萄球菌培养阳性 金黄色葡萄球菌(MRSA)、艰难梭菌和其他耐药微生物；手部卫生、手套和 长袍贴身)。

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).