Guideline Implementation to Decrease Inappropriate Bacteriuria Treatment

对退伍军人医疗保健的预期影响：尿路感染(UTI)是最多的 常见的医院获得性感染。然而，大多数院内导尿管的病例- 伴发尿路感染(CAUTI)实际上是无症状菌尿(ABU)。阿布不是 这是一种临床上意义重大的疾病，治疗不太可能带来好处。滥用职权的过度治疗 是一个质量、安全和成本问题，特别是当不必要的抗生素导致 耐药菌群。我们建议将临床实践与已公布的指南保持一致 显著降低退伍军人中CAUTI和相关的不当抗生素使用的潜力 医院。我们的研究还将提供关于如何最大限度地提高审计有效性的信息- 反馈以实现住院退伍军人管理局指导方针的遵守。 项目背景/基本原理：循证指南建议提供者既不 对大多数留置尿管的患者进行ABU筛查或治疗。然而，这两者之间的一个显著差距 指南和临床实践在我们的退伍军人医院和整个 世界。由于许多VA患者同时处于急性护理环境和亚急性护理环境中，例如 中长期护理，有合法需要导尿管的，问题是 导管相关ABU的过度治疗是VA的一个活跃问题。 项目目标：我们假设实施现有的循证指导方针 关于不治疗ABU将大大减少治疗中不必要的抗生素使用 ABU和误诊CAUTI的发生率。我们的首要目标是提高产品的质量 在特定临床结果方面对ABU的关注(不适当的筛查和 (通过实施审计反馈战略)。我们还假设 审计反馈战略的成功实施将导致可衡量的变化 临床医生对ABU实践指南的了解和态度。我们的第二个目标是 通过调查评估实施指南对临床医生指南知晓率的影响， 熟悉度、接受度和结果预期。 项目方法：我们的指导方针实施战略将采用审计反馈，作为 根据已建立的指南进行处方后抗菌药物审查。的研究人群 临床结果是干预地点(弗吉尼亚州休斯顿)特定病房的所有住院患者 控制点(弗吉尼亚州圣安东尼奥)。我们的研究对象是审计-反馈干预和 调查的对象是这些病房的卫生保健提供者。我们建议进行为期3年的研究。在第一次 每年我们将观察不适当筛查和治疗ABU的基线发生率 在两个地点都有。在未来两年内，将继续对临床结果进行盲目监测 学习。在第二年，我们会在两个地点分发指引。医院的临床医生 干预现场将通过电话或亲自收到关于以下方面的个性化反馈 他们对菌尿的处理是否符合指南。单位层面的反馈也将是 如果是这样的话。在第三年，个性化反馈将停止，但单位级反馈将停止 继续这样做，因为这是一种可持续的干预。临床医生将完成前/后调查 干预地点第二年和第二年的意识、熟悉度、接受度和结果预期 两个地点在第三年。在第二年个体化干预之间的结果差异 第三年的小组干预将有助于确定必要的干预强度 干预，以便在其他退伍军人管理局设施中传播和实施。

Anticipated Impacts on Veterans' Healthcare: Urinary tract infection (UTI) is the single most common hospital-acquired infection. However, the majority of cases of nosocomial catheter- associated urinary tract infection (CAUTI) are really asymptomatic bacteriuria (ABU). ABU is not a clinically significant condition, and treatment is unlikely to confer benefit. Overtreatment of ABU is a quality, safety, and cost issue, particularly as unnecessary antibiotics lead to emergence of resistant flora. Our proposal to bring clinical practice in line with published guidelines has significant potential to decrease CAUTI and associated inappropriate antibiotic use in VA hospitals. Our study will also provide information about how to maximize effectiveness of audit- feedback to achieve guideline adherence in the inpatient VA setting. Project Background/Rationale: Evidence-based guidelines recommend that providers neither screen for nor treat ABU in most catheterized patients. However, a significant gap between these guidelines and clinical practice has been documented at our VA hospital and throughout the world. Since many VA patients in both acute care settings and sub-acute care settings, such as intermediate and long-term care, have a legitimate need for a urinary catheter, the issue of overtreatment of catheter-associated ABU is an active problem for the VA. Project Objectives: We hypothesize that implementing the existing evidence-based guidelines about non-treatment of ABU will dramatically reduce the unnecessary use of antibiotics to treat ABU and the incidence of incorrectly diagnosed CAUTI. Our first objective is to improve quality of care concerning ABU in terms of specific clinical outcomes (inappropriate screening for and treatment of ABU) through implementation of an audit-feedback strategy. We also hypothesize that successful implementation of an audit-feedback strategy will result in measurable changes in clinicians' knowledge and attitudes concerning ABU practice guidelines. Our second objective is to assess through surveys the effect of the implementation on clinicians' guideline awareness, familiarity, acceptance, and outcome expectancy. Project Methods: Our guidelines implementation strategy will employ audit-feedback, applied as a post-prescription antimicrobial review based on established guidelines. The study population for the clinical outcomes is all inpatients on certain wards at the intervention site (Houston VA) and the control site (San Antonio VA). Our study population for the audit-feedback intervention and surveys is the health care providers on these wards. We propose a 3-year study. During the first year we will observe the baseline incidence of inappropriate screening for and treatment of ABU at both sites. Blinded monitoring of clinical outcomes will continue during the next 2 years of the study. During the second year, we will distribute the guidelines at both sites. Clinicians at the intervention site will receive individualized feedback, either by telephone or in person, about whether their management of bacteriuria was guideline-compliant. Unit-level feedback will also be provided. During the third year, individualized feedback will cease, but unit-level feedback will continue as this constitutes a sustainable intervention. Clinicians will complete pre/post surveys of awareness, familiarity, acceptance, and outcome expectancy at the intervention site in year 2 and at both sites in year 3. Differences in outcomes between the individualized intervention in year 2 and the group-level intervention in year 3 will help to determine the necessary intensity of intervention for dissemination and implementation in other VA facilities.