Understanding and Addressing Variation in Healthcare-Associated Infections After Adult Cardiac Surgery

项目摘要/摘要 每年有近25万名患者接受冠状动脉血管重建术和/或瓣膜修复或置换手术。 在美国。尽管手术护理和技术有所改进，但患者仍然面临着巨大的风险 对生活质量和生存有不利影响的术后并发症。医疗保健-获得性感染 “HAI”(例如，肺、血流、胸骨深部创伤)发生在接受这些治疗的患者中约10%。 运营，并显著增加10-1.3万美元的90天付款。高HAI比率与低HAI比率的患者 医院有更高的重大发病率和死亡率风险(18%比9%)，p&lt；0.001。尽管已经做出了努力 重点关注医院内HAI预防做法(例如，适当的时间和类型的抗生素、加强护理 护理单元捆绑包依从性)，HAI率存在很大的医院间差异。只有2%的医院 HAI比率的变化是由传统因素解释的，这突显了确定重要决定因素的必要性。 我们的团队绘制了为心脏手术患者提供护理服务的网络图，反映了协调 患者疾病管理和护理优化(例如，通信和信息交换) 完成协作任务(例如，患者选择、手术时机、重症监护病房恢复、术后 出院护理)跨多个提供者的专科和设置。我们已经合并了国家行政索赔 在接受耐用左心辅助装置的患者中使用临床登记数据，发现：(1) 服务于种族隔离社区的网络表现出更大的谨慎碎片化(即较弱的连接性 在护理提供者中)比那些服务于更一体化的社区的人更多；(2)更多的护理分散 这些在医院层面运作的网络与90- 日间HAI和(3)护理碎片化(衡量网络性能的指标)和后两者之间的关系 出院付款在很大程度上受术后医院感染的影响。了解障碍和促进者 加强护理提供各阶段(入院前、指数入院、入院后)的护理服务网络 最常见的心脏外科手术的出院)将作为 有针对性的改进策略，以解决医院间HAI的变异性。基于社区的伙伴关系， 帮助患者获得社区和卫生系统资源，并解决医疗保健不平等问题，将 作为制定基于证据、以行动为导向的HAI预防建议的新重点。这个 这项提案的目标是确定护理提供网络中可提高HAI的干预领域 结果。这一大规模混合方法提案旨在解决以下目标：(1)评估提供者护理 分娩网络是心脏手术后感染的重要决定因素；(2) 全面了解实现最佳护理提供的结构性障碍和促进者，以及(3)制定 最佳实践工具包，以解决提供者护理提供网络对心脏手术后感染的影响。

Project Summary/Abstract Nearly 250,000 patients annually undergo surgical coronary revascularization and/or valve repair or replacement in the US. Despite improvements in operative care and technology, patients remain at substantial risk of postoperative complications that adversely impact quality of life and survival. Healthcare-acquired infections “HAIs” (e.g., pulmonary, bloodstream, deep-sternal wound) occur in ~10% of patients undergoing these operations and significantly increase 90-day payments by $10-$13K. Patients at higher versus lower HAI tercile hospitals have higher (18% versus 9%) risk of major morbidity and mortality, p < 0.001. Despite existing efforts focused on in-hospital HAI prevention practices (e.g., appropriate timing and type of antibiotics, nursing intensive care unit bundle adherence), substantial interhospital variability persists in HAI rates. Only 2% of hospital variation in HAI rates is explained by traditional factors, highlighting the need to identify significant determinants. Our team has mapped provider care delivery networks serving cardiac surgery patients that reflect coordination of patient disease management and care optimization (e.g., communication and information exchange) to accomplish collaborative tasks (e.g., patient selection, timing of surgery, intensive care unit recovery, post- discharge care) across multiple provider specialties and settings. We have merged national administrative claims with clinical registry data among patients undergoing durable left ventricular assist devices and found: (1) networks serving racially segregated communities display greater care fragmentation (i.e., weaker connectivity among care providers) than those serving more integrated communities; (2) increased care fragmentation of these networks operating at the hospital level is significantly associated with an increase in the probability of 90- day HAIs and (3) the relationship between care fragmentation (a measure of network performance) and post- discharge payments is significantly mediated by postoperative HAIs. Understanding the barriers and facilitators for enhancing care delivery networks across phases of care delivery (pre-admission, index admission, post- discharge) for the most commonly performed cardiac surgical operations would serve as the foundation for targeted improvement strategies to address interhospital HAI variability. Community-based partnerships, that help patients access community and health system resources as well as address healthcare inequities, would serve as a novel focus for developing evidence-based, action-oriented HAI prevention recommendations. The objective of this proposal is to identify areas of intervention within care delivery networks that enhance HAI outcomes. This large-scale mixed methods proposal addresses the following aims: (1) Evaluate provider care delivery networks as significant determinants of postoperative infections after cardiac surgery; (2) Develop a comprehensive understanding of structural barriers and facilitators to optimal care delivery and (3) Develop a best practices toolkit to address the impact of provider care delivery networks on infections after cardiac surgery.