Promoting De-Implementation of Inappropriate Antimicrobial Use in Cardiac Device Procedures By Expanding Audit and Feedback

通过扩大审计和反馈，促进消除心脏装置手术中不当使用抗菌药物的情况

• 批准号: 10404914
• 负责人: Westyn Branch-Elliman
• 金额: --
• 依托单位: VA BOSTON HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-05-01 至 2025-04-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10404914
• 关键词: Accounting; Acute Renal Failure with Renal Papillary Necrosis; Address; Adoption; Adverse event; Age; Algorithms; Antimicrobial Resistance; Area; Cardiovascular system; Caring; Centers for Disease Control and Prevention (U.S.); Cessation of life; Clinical; Clinical Informatics; Clinical effectiveness; Clostridium difficile; Communicable Diseases; Computerized Medical Record; Data; Defibrillators; Deimplementation; Devices; Diffusion; Documentation; Education; Effectiveness; Electronic Health Record; Electronics; Electrophysiology (science); Evidence based intervention; Feedback; Goals; Guidelines; Health; Hour; Hybrids; Infection; Infection Control; Infection prevention; Informatics; Information Systems; Injury to Kidney; Interruption; Interview; Learning; Life; Longevity; Manuals; Measurement; Measures; Medical Records; Methodology; Methods; Morbidity - disease rate; Outcome; Outcome Measure; Outpatients; Pacemakers; Partner in relationship; Population; Procedures; Process; Prophylactic treatment; Provider; Quality of Care; Recommendation; Reporting; Research; Research Personnel; Research Priority; Resistance to infection; Resources; Savings; Site; Skin; Son; Surgical incisions; System; Testing; Time; Time Series Analysis; Translating; Veterans; Work; adverse outcome; antimicrobial; base; cardiac device; clinical care; clinical practice; design; disorder control; disorder prevention; electronic data; evidence base; formative assessment; healthcare-associated infections; implementation outcomes; implementation science; implementation strategy; implementation study; improved; improved outcome; informatics tool; innovation; insight; member; mortality; novel; prevent; primary outcome; programs; tool; uptake

Background: Cardiac device procedures, such as pacemaker and defibrillator placements, are common and increasing as the population ages. These devices are life-saving for the Veterans who need them, but the pro- cedures can be complicated by highly morbid infections and other adverse events, resulting in poor outcomes. Clinical guidelines recommend administration of pre-procedural antimicrobials to prevent cardiac device infec- tions and early discontinuation of antimicrobials after the procedure to prevent harms caused by unnecessary antimicrobial use, such as kidney injury, C. difficile infections, and antimicrobial resistance. However, these guidelines are rarely applied, resulting in preventable morbidity and mortality, and creating a critical need for research investigating strategies to promote adoption of best practices (e.g., learning) and de-adoption of inef- fective and harmful practices (e.g., unlearning). Significance/Impact: The research in this study closes an important gap in the care of cardiac device recipients and advances several VA HSR&D research priorities, including implementation, informatics, and quality of care. It leverages the strength of the VA electronic health record (EHR) and will provide important insights into clinical informatics methodologies for expanding surveillance of healthcare-associated infections and antimicrobial use to include outpatient and procedural areas. Investigators will also promote understanding about how learning and unlearning processes can be leveraged to enhance adoption of clinical guidelines and de-implementation of ineffective and harmful practices. Innovation: The highly innovative, informatics-based audit and feedback system will advance the field of imple- mentation science by yielding a new strategy for promoting de-implementation of inappropriate practices. Les- sons learned about how to implement novel, real-time informatics tools and adapt and scale them will also be generalizable to procedural areas with limited resources to support surveillance. Aim I: Tests the hypothesis that a multi-faceted implementation strategy including automated audit and feed- back, education of electrophysiology team members, local adaptation, and blended facilitation with engagement of local champions, will improve adoption of antimicrobial prophylaxis guidelines for electrophysiology proce- dures at three VA facilities, using a stepped-wedge, Hybrid III design. Primary outcome is adoption of guideline- recommended antimicrobial use. Clinical effectiveness will be assessed through measurement of clinical out- comes (CIED infections, AKI, and C. difficile). Aim II: Measures the feasibility of using an informatics-based algorithm to measure outcomes and guideline- concordance following cardiac device procedures at 78 facilities and tests the passive diffusion of reports. Methodology: There is a major gap in studies evaluating de-implementation of ineffective practices. This study has two complimentary aims and will address this gap by testing the utility of a highly innovative clinical infor- matics tool developed using the robust VA EHR. The informatics tool combines feedback about best practices and positive clinical outcomes (learning) with feedback about ineffective and harmful practices and adverse clin- ical outcomes (unlearning) as part of a multi-faceted implementation strategy. Aim I will test the multi-faceted implementation strategy at three VAs using a Hybrid III design. Aim II will test the tool’s scalability and dissemi- nation throughout the VA and will identify barriers to expansion and potential solutions. Implementation/Next Steps: The central aim of this study is to implement ways to promote best practices. Tools developed during the course of the study will be widely disseminated throughout the VA to enhance the quality of care and will be provided to key operational partners, who can adapt the clinical informatics tools to promote best practices in other clinical cares with limited infection prevention and stewardship resources.

背景：心脏设备程序，如起搏器和除颤器放置，是常见的， 随着人口老龄化而增加。这些设备是拯救生命的退伍军人谁需要他们，但亲- 高度病态的感染和其他不良事件会使病情复杂化，导致不良结果。 临床指南建议术前给予抗菌剂，以防止心脏器械感染， 术后早期停用抗菌药物，以防止不必要的 抗菌药物使用，如肾损伤，C.艰难梭菌感染和抗菌素耐药性。但这些 指南很少得到应用，导致可预防的发病率和死亡率，并迫切需要 研究调查促进采用最佳实践的策略（例如，学习）和取消采用INEF- 有效和有害的做法（例如，忘却）。 意义/影响：本研究填补了心脏器械接受者护理方面的一个重要空白 并推进了几个VA HSR&D研究重点，包括实施，信息学和护理质量。 它利用VA电子健康记录（EHR）的优势，将为临床 扩大卫生保健相关感染和抗菌药物使用监测的信息学方法 包括门诊和手术区域。研究人员还将促进对学习如何 和遗忘过程可以被用来加强临床指南的采用和 无效和有害的做法。 创新：高度创新的、基于信息的审计和反馈系统将推动实施领域的发展。 心理科学产生了一个新的战略，促进不适当的做法去执行。莱斯 儿子们学会了如何实施新颖的，实时的信息学工具，并适应和规模，他们也将 可推广到支持监督的资源有限的程序领域。 目的一：测试的假设，一个多方面的实施战略，包括自动审计和饲料， 背部，电生理学团队成员的教育，当地适应，以及混合促进与参与 地方冠军，将提高采用抗菌预防指南的电生理过程， 在三个VA设施，使用阶梯楔，混合III设计。主要成果是通过指南- 建议使用抗菌剂。临床有效性将通过测量临床效果来评估 来（CIED感染、阿基和C.艰难）。 目标二：测量使用基于信息的算法来测量结果和指南的可行性- 78家机构心脏器械手术后的一致性，并测试报告的被动传播。 方法：在评价取消无效做法的研究方面存在重大差距。本研究 有两个互补的目标，并将通过测试高度创新的临床信息的实用性来解决这一差距， 使用强大的VA EHR开发的matics工具。信息学工具结合了关于最佳做法的反馈 和积极的临床结果（学习）与反馈有关的无效和有害的做法和不良临床- 作为多方面实施战略的一部分，取得了积极的成果（忘却）。目标我将测试的多方面 在三个VA使用混合III设计的实施战略。Aim II将测试该工具的可扩展性，并传播 在整个弗吉尼亚州的国家，并将确定扩展和潜在的解决方案的障碍。 执行/下一步：这项研究的中心目标是落实推广最佳做法的方法。工具 在研究过程中开发的将在整个VA广泛传播，以提高质量 并将提供给关键的业务合作伙伴，他们可以调整临床信息学工具， 在感染预防和管理资源有限的情况下，在其他临床护理中采用最佳做法。