Mentored Enhanced Implementation and Evaluation of National VA Mandates To Prevent The Spread Of C Difficile infection

背景：艰难梭菌感染（CDI）的发病率和严重程度正在增加； CDI 影响 50 万美国人 每年造成 20,000 人死亡，并给医疗保健带来巨大的经济负担 机构。预防 CDI 至关重要，退伍军人管理局多重耐药菌 (MDRO) 项目办公室 最近强制要求在 VA 设施中实施一套预防 CDI 的措施。该捆绑包包括适当的诊断 测试、手部卫生合规性优化、CDI 接触隔离以及环境清洁 CDI 患者的房间。然而，它没有提出最佳实施策略以确保 成功应用这些干预措施，也没有规定如何采取这些措施。 各个机构实施和遵守这些建议措施的情况差异很大。 具体目标：该项目的中心假设是与以下相关的实践和方法的变化 环境清洁——尤其是日常清洁——将成为变量的主要贡献者 实施 CDI 捆绑和 CDI 费率。其基本原理源于文献确定频繁 艰难梭菌的环境污染以及我们试点工作的结果。我们的目标是评估工作 使用混合方法进行捆绑实施的系统障碍和促进因素。具体目标 对于这个项目是： 1. 评估 10 个 VA 站点现有 CDI 捆绑实施与 CDI 率之间的关联。 2. 确定促进或阻碍 10 个 VA 站点实施 CDI 捆绑包的做法。 3. 使用快速计划-实施-研究-试验并最终确定改善退伍军人事务部某一地点环境清洁的工具 质量改进的行动周期方法。 方法：我们将使用创新的患者安全系统工程计划 (SEIPS) 2.0 模型 工作系统和患者安全作为与 iPARiHS 框架集成的研究框架。这个模型，如 以及有关指南实施的一般文献，将指导面试问题。参加者将包括 护士、医生、患者、环境服务和医院领导。我们将直接进行 基于 SEIPS 2.0 模型对医护人员的观察。我们将观察病房、个人、 任务和组织，以更好地了解围绕护理过程的整体工作系统 CDI 患者。 影响：预防艰难梭菌是 VA 的首要任务，并实施艰难梭菌预防 类似于已经建立的耐甲氧西林金黄色葡萄球菌 (MRSA) 束， 近期已在全国推广。然而，我们制定和实施遏制战略的能力 由于对影响艰难梭菌获得、传播和预防的因素了解有限，阻碍了艰难梭菌的发展。 VA 设施中的艰难梭菌。实现本提案目标的直接好处将是产生 有关使用系统工程方法实施的障碍和促进因素的重要数据。 我们的研究将产生具有广泛相关性和可移植性的数据、方法和工具， 减少医疗相关感染 (HAIs) 的潜力，包括但不限于艰难梭菌感染。 这是第一项系统地考察实施“一带一路”倡议的障碍和促进因素的研究。 CDI 预防包。我们的项目的创新之处在于它将采用SEIPS 2.0框架来进行 CDI 预防的完整工作系统分析；使用多种互补的数据方法 收藏；不仅要考虑参与直接患者护理的医护人员，还要考虑辅助人员 对于成功预防 CDI 至关重要。我们的研究方法和途径可能不仅仅适用于CDI 还有其他医院感染，并将扩大患者安全和感染控制领域。

Background: C. difficile infection (CDI) is increasing in incidence and severity; CDI affects 500,000 Americans each year, causes 20,000 deaths annually, and imposes a significant financial burden on healthcare institutions. Preventing CDI is essential, and the VA Multidrug Resistant Organism (MDRO) Program Office recently mandated a bundle for prevention of CDI in VA facilities. The bundle includes appropriate diagnostic testing, optimization of hand hygiene compliance, contact isolation for CDI, and environmental cleaning of rooms of patients with CDI. However, it does not address optimum implementation strategies to ensure successful application of these interventions, nor does it prescribe how these measures may be undertaken. Implementing and adhering to these recommended measures varies considerably across institutions. Specific Aims: The central hypothesis of this project is that variation in practices and approaches related to environmental cleaning—particularly daily cleaning—will emerge as major contributors to variable implementation of the CDI bundle and CDI rates. The rationale stems from the literature identifying frequent environmental contamination with C. difficile and the findings of our pilot work. Our objective is to assess work system barriers and facilitators to bundle implementation using a mixed-methods approach. The specific aims for this project are: 1. To evaluate the association between existing CDI bundle implementation and CDI rates at 10 VA sites. 2. To identify practices that facilitate or impede CDI bundle implementation at 10 VA sites. 3. Pilot and finalize tools to improve environmental cleaning at one VA site using the rapid plan-do-study- act cycle methodology of quality improvement. Methods: We will use the innovative Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model of work system and patient safety as the study framework integrated with the iPARiHS framework. This model, as well as general literature on guideline implementation, will guide interview questions. Participants will include nurses, physicians, patients, environmental services and hospital leadership. We will conduct direct observations of healthcare workers based on the SEIPS 2.0 model. We will observe patient rooms, individuals, tasks, and organization to better understand the overall work system that surrounds the process of care for CDI patients. Impact: Prevention of Clostridium difficile is a priority of the VA, and implementation of a C. difficile prevention bundle, akin to an already established methicillin-resistant Staphylococcus aureus (MRSA) bundle, has recently been rolled out nationally. However, our ability to devise and implement strategies for containment of C. difficile is hampered by a limited understanding of factors influencing acquisition, spread, and prevention of C. difficile in VA facilities. Immediate benefits of achieving the objectives of this proposal will be generation of important data regarding barriers and facilitators of implementation using a systems engineering approach. Our study will produce data, methods, and tools that have widespread relevance and portability, with the potential to reduce healthcare-associated infections (HAIs) including but not limited to C. difficile infection. This is the first research study to systematically examine barriers and facilitators of implementation of a prevention bundle for CDI. Our project is innovative in that it will employ the SEIPS 2.0 framework to undertake a complete work systems analysis for CDI prevention; use a number of complementary approaches to data collection; and consider not just healthcare workers involved in direct patient care, but also ancillary staff who are critical to successful CDI prevention. Our study methods and approach may be widely used not just for CDI but also other HAIs, and will add to the fields of patient safety and infection control.