Comparative safety and effectiveness of isolation in VHA community living centers

描述(由申请人提供)： 摘要：VHA通过MRSA预防倡议在感染控制方面处于领先地位，以预防急性护理和长期护理中的感染。MRSA预防倡议的一个基石是在所有患者入院、出院和每半年进行一次MRSA检测。在美国，没有其他医疗系统获得如此多的MRSA数据。那些被发现患有MRSA的急性护理患者被隔离在私人房间，医护人员(HCW)被要求使用长袍和手套进行接触。在急性护理中，隔离与更少的HCW就诊和更严重的抑郁、焦虑、精神错乱、更差的过程测量和更多的不良事件(主要是跌倒和压疮)有关。长期护理机构(LTCF)目前的感染预防做法来自于为急性护理环境设计的做法，可能不适合长期护理机构的人群。在社区生活中心(CLCs)，VHA致力于为退伍军人提供体现家庭式环境属性的长期住宿护理。CLCS中隔离的使用因设施而异，从非常激进的(长期隔离那些不能进行个人卫生或有活动性感染的设施-符合退伍军人管理局MRSA PI的设施)到保守的(对所有患者使用标准预防措施-主要是手卫生-符合疾控中心指南的设施)。这些政策基于低质量的数据，而且CLC之间这种做法差异的影响尚不清楚；然而，这些问题对居住在CLC的近45,000名退伍军人至关重要(根据VHA/CDC最近的一份出版物，高达58%的CLC居民患有MRSA)。CLC的居民经常需要转移到急性护理机构进行感染，并导致了急性护理的暴发。由于CLC既是居家般的住所，也是医疗设施，理解CLC中的MRSA隔离做法需要采用多种方法，既要考虑到国家比较有效性数据，又要考虑到遵守感染预防政策的障碍的一线观点。为了进行全国性的比较有效性研究，我们将首先开发和管理一项针对所有CLC的调查，以评估MRSA隔离做法(作为暴露)，并使用独特的VHA二级数据库来评估结果、MRSA感染和感染(IPEC)和意外后果(MDS 3.0)。将使用直接观察法来量化这10个CLC中的HCW与居民之间的相互作用。调查结果将为招募10个地理上分散的社区卫生服务中心的社区卫生工作者提供一对一面试的信息，以了解卫生工作者的信念、知识和对遵守感染预防做法的障碍的看法。这些访谈将确定感染预防教育的教育需求。通过使用独特的VHA数据的这些综合项目，我们希望确定隔离的哪些方面与1)MRSA预防和2)意外后果相关，以及未来的感染预防努力如何最好地提高患者的整体安全。这些信息将促进长期护理中患者安全的科学研究，并为VHA CLC预防感染提供更合理的政策和教育。

DESCRIPTION (provided by applicant): Abstract: The VHA has been a leader in infection control with the MRSA Prevention Initiative to prevent infections in both acute-care and long-term care. A cornerstone of the MRSA Prevention Initiative is testing all patients for MRSA on admission, discharge and semi-annually. No other healthcare system in the US obtains this amount of MRSA data. Those acute-care patients found to have MRSA are isolated in a private room and healthcare workers (HCW) are required to use of gown and gloves for contact. In acute-care isolation has been associated with fewer HCW visits and greater depression, anxiety, delirium, worse process measure and more adverse events (primarily falls and pressure ulcers). Current infection prevention practices in long-term care facilities (LTCFs) are adopted from those designed for acute-care settings and may not be appropriate for a LTCF population. In Community Living Centers (CLCs), the VHA is committed to providing Veterans with long-term, residential care that embodies the attributes of a home-like environment. The use of isolation in CLCs varies by facility from very aggressive (long-term isolation of those unable to perform personal hygiene or with active infections-facilities adhering to the VA MRSA PI) to conservative (using standard precautions for all patients-primarily hand hygiene-facilities adhering to CDC guidelines). These policies are based on low quality data and the effect of this practice variation between CLCs is unknown; however these issues are of critical significance to the nearly 45,000 Veterans residing in CLCs (according to a recent VHA/CDC publication up to 58% of CLC residents have MRSA). CLC residents often require transfer to acute-care facilities for infections and have led to outbreaks n acute-care. Because CLCs constitute both a home-like residence and a medical facility, understanding MRSA isolation practices in CLCs requires a multi-method approach that accounts for both national comparative effectiveness data and front-line perspectives on the barriers to adhering to infection prevention policies. To pursue a nationwide comparative effectiveness study we will first develop and administer a survey to all CLCs to assess MRSA isolation practice (as an exposure) and use unique VHA secondary databases for outcomes MRSA acquisition and infection (IPEC) and unintended consequences (MDS 3.0). Direct observation methods will be employed to quantify HCW-resident interactions at these 10 CLCs. Survey results will inform recruitment for one-on-one interviews with CLC HCWs at 10 geographically dispersed CLCs to understand HCW beliefs, knowledge and perceptions of barriers to adherence with infection prevention practices. These interviews will identify educational needs for infection prevention education. Through these integrated projects that use unique VHA data we expect to determine which aspects of isolation are associated with 1) MRSA prevention and 2) unintended consequences and how future infection prevention efforts can best improve overall patient safety. This information will advance the science of patient safety in long-term care and inform more rational policy and education for infection prevention in VHA CLCs.