Implementation and Evaluation of a Video-based Prospective Feedback Intervention to Improve Antimicrobial Stewardship in Neonatal Intensive Care Units

总结/摘要 滥用抗菌素的问题是众所周知的，是所有主要的 公共卫生、传染病和美国初级保健协会。这反映了存在无法治愈的 细菌感染，新抗生素的生产商管道很浅，以及持续滥用抗生素， 供应商的抗菌药物。在新生儿重症监护室（NICU）环境中，抗生素是最常见的抗生素。 经常使用的药物，而且经常使用不当。这种使用与增加 细菌耐药性、住院时间延长、坏死性小肠结肠炎，甚至死亡。药物 由于感染性和非感染性条件相似，NICU中的使用决策可能很困难 常常导致经验性的过度治疗。因此，在抗生素中存在实质性变化并不奇怪。 使用NICU。抗生素管理计划（ASP）减轻了贫困的后果 使用抗生素可改善患者结局，减少不良事件，改善细菌感染 经济效益和节约。建议使用几种ASP策略，无论它们多么常见 实施问题包括缺乏供应商的购买，对最佳实践的共识，注意 处方医生和其他管理患者的工作人员之间的互动，以及根据临床和 体制背景。这些挑战在患者高度异质性的环境中加剧， 适应症和缺乏专家共识的治疗，如新生儿重症监护病房。 我们建议评估一种创新的、可扩展的抗菌管理干预措施，称为ECHO。 NICU的ASP参与了美国最大的全州围产期QI协作。干预 将前瞻性反馈（CDC推荐的ASP实践）与ECHO远程学习平台配对 （社区医疗保健结果的扩展）。ECHO是一种基于证据的实践方法 自2003年以来，在全球超过120个保健协作中使用了传播方法。ECHO‐ASP的两个部分 干预-前瞻性反馈和ECHO方法-是基于专家推动的， 基于案例的学习模型，适合临床医生如何倾向于学习和建立实践共识。 该项目的具体目标是：1）评价ECHO‐ASP干预措施的实施情况 包括实施的障碍和促进因素，基于视频的前瞻性研究中心参与 反馈和审计会议，向其他当地NICU处方者传播会议结果， 干预的可接受性和持久性，以及抗生素处方的实践共识; 2） 评价ECHO ASP干预对患者护理结局（包括抗生素）的有效性 使用、药物相关不良事件和其他临床并发症; 3）评估 ECHO ASP干预措施，包括实施成本和对护理成本的影响。

Summary/Abstract The problem of antimicrobial misuse is well known and is a high priority action item for all of the major public health, infectious disease and US primary care societies. This reflects the existence of untreatable bacterial infections, a shallow manufacturer pipeline for new antibiotics, and continued misuse of antimicrobials by providers. In the neonatal intensive care unit (NICU) setting, antibiotics are the most frequently used medications, and very often inappropriately. Such use is associated with increased bacterial resistance, increased hospital length of stay, necrotizing enterocolitis, and even death. Drug usage decisions can be difficult in the NICU as infectious and non‐infectious conditions present similarly often leading to empiric overtreatment. Thus, it is not surprising there is substantial variation in antibiotic use among NICUs. Antimicrobial stewardship programs (ASP) mitigate against the consequences of poor antibiotic use resulting in improved patient outcomes, fewer adverse events, improved bacterial susceptibilities, and economic savings. Several ASP strategies are recommended, however common implementation problems include lack of provider buy‐in, consensus on best practice, attention to interactions among prescribers and other staff who manage patients, and tailoring of ASPs to clinical and institutional contexts. These challenges are exacerbated in settings in which high heterogeneity in patient indications and lack of expert consensus on treatment is present, such as the NICU. We propose to evaluate an innovative, scalable antimicrobial stewardship intervention called ECHO‐ ASP in NICUs participating in the largest statewide perinatal QI collaborative in the US. The intervention pairs prospective feedback (an ASP practice recommended by CDC) with the ECHO tele‐learning platform (Extension for Community Healthcare Outcomes). ECHO is an evidence‐based method of practice dissemination used globally in >120 health collaborations since 2003. Both parts of the ECHO‐ASP intervention—prospective feedback and the ECHO methodology—are grounded in an expert‐facilitated, case‐based learning model tailored to how clinicians are inclined to learn and build practice consensus. The Specific Aims of the project are to: 1) Evaluate the implementation of the ECHO‐ASP intervention including barriers and facilitators to implementation, site participation in video‐based prospective feedback and audit sessions, dissemination of session results to other local NICU prescribers, perceived acceptability and durability of the intervention, and practice consensus on antibiotic prescribing; 2) Evaluate the effectiveness of the ECHO ASP intervention on patient care outcomes, including antibiotic use, drug‐related adverse events, and other clinical complications; 3) Evaluate the cost implications of the ECHO ASP intervention, including implementation costs and effects on costs of care.