Leveraging inpatient antimicrobial stewardship infrastructure to improve antimicrobial-prescribing at hospital discharge

利用住院患者抗菌药物管理基础设施改善出院时的抗菌药物处方

• 批准号: 10421218
• 负责人: Daniel Livorsi
• 金额: --
• 依托单位: IOWA CITY VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-07-01 至 2026-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10421218
• 关键词: Address; Admission activity; Adverse drug event; Antimicrobial Resistance; Attitude; Case Mixes; Centers for Disease Control and Prevention (U.S.); Characteristics; Clinical; Clostridium difficile; Communicable Diseases; Communities; Data; Development; Dose; Feedback; Fostering; Funding; Future; Goals; Health Priorities; Healthcare; Home; Hospital Administration; Hospitals; Infection; Infrastructure; Inpatients; Intervention; Interview; Knowledge; Length of Stay; Literature; Manuals; Measurement; Methodology; Modeling; Monitor; Outcome; Paper; Patient Admission; Patients; Perception; Performance; Pharmaceutical Preparations; Process; Promoting Action on Research Implementation in Health Services framework; Public Health; Qualitative Methods; Resources; Risk; Risk Factors; Safety; Services; Site; Site Visit; Standardization; Structure; Surveys; Targeted Research; Time; Variant; Veterans; Veterans Health Administration; Visit; Work; acute care; antimicrobial; base; dashboard; design; emerging antimicrobial resistance; evidence base; improved; innovation; patient oriented; patient safety; patient subsets; pilot test; programs; tool

Background: Antimicrobial overuse is one of the strongest risk factors for the emergence of antimicrobial resistance, an urgent public health problem. Antimicrobial stewardship programs (ASPs) are hospital-based programs that can reduce unnecessary inpatient antimicrobial use and are therefore an essential tool for addressing the crisis of antimicrobial resistance. ASPs are mandated in VHA. Significance: VHA hospitals are only required to monitor their inpatient antimicrobial use. However, at least 40% of antimicrobial exposure associated with a VHA hospital stay is prescribed at hospital discharge and is taken by the patient after discharge (i.e. post-discharge). These post-discharge antimicrobial prescriptions are frequently unnecessary or sub-optimal. Reducing post-discharge antimicrobial overuse will minimize patient harm, such as Clostridioides difficile infections, antimicrobial resistance, and adverse drug events. Innovation and Impact: This proposal will address two critical gaps in the literature. First, standard ASP metrics do not capture post-discharge antimicrobial use and therefore miss a substantial amount of hospital- related antimicrobial exposure. This proposal will evaluate factors that contribute to variation in post-discharge antimicrobial use across patients and hospitals in order to inform both metric development and the design of future stewardship interventions. Second, while there are evidence-based strategies for safely reducing inpatient antimicrobial use, it is unclear how current inpatient ASP activities can decrease post-discharge antimicrobial overuse. This proposal will explore how inpatient ASP infrastructure, which all VHA hospitals are expected to have, can be leveraged to reduce unnecessary post-discharge antimicrobial-prescribing. Specific Aims: Aim 1: Identify factors that contribute to variation in post-discharge antimicrobial use in VHA acute-care admissions across all facilities by evaluating potential patient-level, hospital-level, and environmental effects. Identify hospitals that have low observed-to-expected post-discharge antimicrobial use, low risk-adjusted inpatient antimicrobial use, and perform well on clinical outcomes in antimicrobial-treated patients. Aim 2: Determine whether being admitted to a hospital with a discharge-focused stewardship process is associated with less post-discharge antimicrobial exposure, after adjusting for differences in case-mix, ID expertise, inpatient antimicrobial exposure, and the intensity of inpatient ASP activities. Aim 3: Using qualitative methods, evaluate attitudes and processes that impede or foster reductions in unnecessary post-discharge antimicrobial use. We will perform site visits at 6 high- and 4 low-performing sites, as identified in Aim 1. Methodology: Aim 1 will use VINCI data and linear mixed models to identify factors that influence post- discharge antimicrobial use. Aim 1 will also rank hospitals on their performance on inpatient and post- discharge antimicrobial use plus associated clinical outcomes. In Aim 2, we will leverage VINCI data and findings from a mandatory hospital-level stewardship survey conducted in VHA during November 2020. We will evaluate the effect of a discharge-specific stewardship process on post-discharge antimicrobial use. In Aim 3, we will conduct semi-structured interviews with key stakeholders at 10 hospitals to explore determinants of post-discharge antimicrobial overuse and perceptions of the post-discharge antimicrobial use metric that we developed in Aim 1. Our approach will be based in the i-PARIHS framework. Next Steps/Implementation: The standardized hospital-level metrics we develop in Aim 1 could be incorporated into an interactive ASP dashboard our Patient Safety Center of Inquiry has already built and is pilot-testing in VISN 23. Our findings from Aims 2 and 3 could be incorporated into future stewardship surveys within VHA while informing the processes local ASPs choose to implement to reduce post-discharge antimicrobial overuse. Our findings could serve as the basis for a multicenter, audit-and-feedback trial focused on stewardship at hospital discharge and future work around re-designing ASP processes at discharge.

背景：抗菌药物的过度使用是导致抗菌药物出现的最大危险因素之一。 耐药性是一个紧迫的公共卫生问题。抗菌药物管理计划（ASP）以医院为基础 可以减少不必要的住院抗菌药物使用的计划，因此是一个重要的工具， 解决抗菌药物耐药性危机。ASP在VHA中被授权。 意义：VHA医院只需要监测其住院抗菌药物的使用情况。但至少 与VHA住院相关的40%的抗菌剂暴露在出院时处方， 患者出院后（即出院后）服用。这些出院后的抗菌处方是 通常是不必要的或次优的。减少出院后抗菌药物的过度使用将最大限度地减少患者 危害，如艰难梭菌感染、抗菌素耐药性和药物不良事件。 创新和影响：本提案将解决文献中的两个关键空白。一、标准ASP 指标没有捕获出院后抗菌药物的使用，因此错过了大量的医院- 相关的抗菌剂暴露。该提案将评估导致出院后变化的因素 抗菌药物在患者和医院中的使用，以便为指标的制定和 未来的管理干预。其次，虽然有基于证据的安全减少 住院患者抗菌药物使用情况，目前尚不清楚目前住院患者ASP活动如何减少出院后 抗生素滥用该提案将探讨如何住院ASP基础设施，其中所有VHA医院是 预期具有的，可以用来减少不必要的出院后抗菌药物处方。 具体目的：目的1：确定导致VHA出院后抗菌药物使用变化的因素 通过评估潜在的患者水平、医院水平和 环境影响。确定出院后抗菌药物使用低于预期的医院， 低风险调整的住院患者抗菌药物使用，并在抗菌药物治疗的临床结局中表现良好 患者目标2：确定是否入住一家以出院为重点的管理流程的医院 在调整病例组合、ID、 专业知识、住院患者抗菌药物暴露和住院患者ASP活动强度。目标3：使用定性 方法，评估阻碍或促进减少不必要的出院后的态度和过程 抗菌剂的使用。我们将在目标1中确定的6个高性能研究中心和4个低性能研究中心进行研究中心访视。 方法：目标1将使用芬奇数据和线性混合模型来确定影响后 排出抗菌药物。Aim 1还将根据医院在住院和术后的表现对医院进行排名。 出院抗菌药物使用情况及相关临床结局。在目标2中，我们将利用芬奇数据， 2020年11月在VHA进行的强制性医院管理调查结果。我们将 评价出院特定管理过程对出院后抗菌药物使用的影响。在目标3中， 我们将对10家医院的主要利益相关者进行半结构化访谈，以探讨 出院后抗菌药物过度使用和对出院后抗菌药物使用指标的看法， 在Aim 1中开发。我们的方法将基于i-PARIHS框架。 下一步/实施：我们在目标1中开发的标准化医院级指标可以是 整合到我们的患者安全调查中心已经建立的交互式ASP仪表板中， 在VISN 23中进行试点测试。我们在目标2和3中的发现可以纳入未来的管理调查 在VHA内部，同时告知当地ASP选择实施的流程，以减少出院后 抗生素滥用我们的研究结果可以作为一个多中心的基础， 关于出院时的管理工作和未来围绕出院时重新设计ASP流程的工作。