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

背景：C.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 机构职能体系预防CDI至关重要，VA多药耐药微生物（MDRO）项目办公室 最近授权了一个捆绑包，用于预防VA设施中的CDI。捆绑包包括适当的诊断 测试，优化手部卫生合规性，CDI接触隔离， CDI患者的房间。然而，它没有解决最佳实施战略，以确保 它既没有规定如何成功地实施这些干预措施，也没有规定如何采取这些措施。 各机构执行和遵守这些建议措施的情况差别很大。 具体目标：本项目的中心假设是， 环境清洁，特别是日常清洁，将成为变量的主要贡献者。 实施CDI捆绑包和CDI费率。理由来自文献， 环境污染C. difficile和我们的试点工作的结果。我们的目标是评估工作 使用混合方法捆绑实施的系统障碍和促进因素。具体目标 为这个项目是： 1.评价10个VA研究中心现有CDI捆绑包实施与CDI率之间的相关性。 2.确定在10个VA站点促进或阻碍CDI捆绑包实施的实践。 3.在一个退伍军人事务部场地使用快速规划-实施-研究- 质量改进的行动循环法。 方法：我们将使用创新的患者安全系统工程倡议（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。该模型作为 以及关于准则实施的一般文献，将指导面试问题。与会者将包括 护士、医生、病人、环境服务和医院领导。我们将直接进行 基于SEIPS 2.0模型的医疗保健工作者观察。我们会观察病人的房间，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的优先事项，实施C。困难预防 束，类似于已经建立的耐甲氧西林金黄色葡萄球菌（MRSA）束， 最近在全国范围内推广。然而，我们制定和实施遏制恐怖主义战略的能力 C.艰难梭菌是阻碍了有限的了解影响因素的收购，传播和预防， C.在VA设施中很难。实现本建议目标的直接好处是， 使用系统工程方法，提供关于执行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， 减少医疗保健相关感染（HAI）的潜力，包括但不限于C.艰难感染 这是第一项系统地审查执行《公约》的障碍和促进因素的研究， CDI的预防包。我们的项目是创新的，因为它将采用SEIPS 2.0框架， 对CDI预防进行完整的工作系统分析;使用一些互补的数据方法 收集;不仅考虑直接参与患者护理的医护人员，还考虑辅助人员， 是成功预防CDI的关键。我们的研究方法和途径可能会被广泛使用，而不仅仅是CDI 而且还包括其他HAI，并将增加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.