Reducing VA Healthcare-Associated Infections through Antibiotic StEwardship (RAISE)

背景：艰难梭菌感染(CDI)的发病率和严重性正在增加，退伍军人 人群患这种与医疗保健相关的感染的风险较高。尽管退伍军人事务部采取了预防措施，CDI 费率(根据设施复杂性和患者组合进行了调整)在退伍军人管理局各地点继续存在很大差异。抗生素 管理计划(AS)已被证明可以降低医院的CDI发生率，因此它们是一个关键 CDI预防计划的组成部分。然而，还不清楚哪种AS策略在哪些方面最有效 具体减少CDI，以及如何将这些作为战略有效实施。 具体目标：我们的长期目标是使用实施科学来开发和评估干预措施，以 减少CDI等与医疗保健相关的感染。我们的目标是了解背景和工作系统 作为AS干预措施一部分的因素及其对临床结果的影响。医疗保健机构 研究与质量(AHRQ)已承诺资助我们的学术附属机构(PI：Safdar)进行一项 1)测量核心AS干预的影响的随机对照试验(处方前授权， PPA)关于降低CDI比率和2)使用系统工程框架来评估上下文， 实施，以及影响临床结果的工作系统因素。此合作评估 该计划将利用AHRQ资金来评估第二个核心的临床和实施结果 以减少CDI为目标的干预。在这里，我们将评估带有反馈的前瞻性审计(PAF) AS干预及其在退伍军人事务部的实施，以便为 退伍军人管理局设施的具体需求。我们这个项目的目标是： 1：使用综合促进措施评估PAF干预措施的实施结果 卫生服务研究行动(PARiHS)和患者安全系统工程倡议 (SEIPS)模型。 2：探索核心AS干预(PAF)对临床结果的影响-包括CDI率-in VA设置。 3：为退伍军人管理局制定和传播可持续的建议，以减少CDI。 方法：采用导师式实施方法，帮助6个VA住院单位优化实施 减少氟喹诺酮类药物使用的PAF干预措施。我们将使用系统工程框架来 作为多案例研究设计的一部分，评估实施的保真度、可接受性和可行性 在每个参赛单位。我们还将在每个站点使用PRE和 干预后数据，以衡量干预对临床结果的影响，如CDI率和 抗生素的使用。 影响：该项目将使用iPARiHS和SEIPS框架来承担完整的工作系统 分析--系统地检查作为干预措施的执行障碍和促进者。通过合作 本项目配合AHRQ资助的试验，我们将制定切实可行的实施方案 关于两个核心干预措施(PPA和PAF)的建议。这些执行建议将 填补AS计划指南中的一个关键空白，并将加强整个退伍军人事务部的CDI预防举措。

Background: Clostridium difficile infections (CDI) are increasing in incidence and severity, and the Veteran population is at elevated risk of this healthcare-associated infection. Despite prevention initiatives in VA, CDI rates (adjusted for facility complexity and patient mix) have continued to vary widely across VA sites. Antibiotic stewardship (AS) programs have been shown to reduce hospital-onset CDI rates, and so they are a key component of CDI prevention programs. However, it is unknown which AS strategies are most effective in reducing CDI specifically and how to implement these AS strategies effectively. Specific Aims: Our long-term goal is to use implementation science to develop and evaluate interventions to reduce healthcare-associated infections like CDI. We aim to understand the contextual and work system factors that are part of AS interventions and their impact on clinical outcomes. The Agency for Healthcare Research and Quality (AHRQ) has committed funding to our academic affiliate (PI: Safdar) to conduct a randomized controlled trial to 1) measure the impact of a core AS intervention (preprescription authorization, PPA) on reducing CDI rates and 2) use a systems engineering framework to evaluate the contextual, implementation, and work system factors that contribute to clinical outcomes. This Partnered Evaluation Initiative will leverage AHRQ funding to evaluate the clinical and implementation outcomes of a second core AS intervention with the goal of reducing CDI. Here, we will evaluate a prospective audit with feedback (PAF) AS intervention and its implementation in a VA context in order to produce implementation strategies for the specific needs of VA facilities. Our aims for this project are: 1: Evaluate implementation outcomes of a PAF intervention using a blend of the Integrated Promoting Action on Research in Health Services (PARiHS) and Systems Engineering Initiative for Patient Safety (SEIPS) models. 2: Explore the impacts of a core AS intervention (PAF) on clinical outcomes - including CDI rates - in VA settings. 3: Develop and disseminate sustainable recommendations for AS in VA aimed at reduction of CDI. Methods: We will use Mentored Implementation methods to help six VA inpatient units optimize and implement PAF interventions to reduce the use of fluoroquinolones. We will use systems engineering frameworks to evaluate the fidelity, acceptability, and feasibility of the implementations as part of a multiple case study design at each participating unit. We will also conduct an interrupted time series analysis at each site using pre- and post-intervention data to measure the impact of the intervention on clinical outcomes such as CDI rates and antibiotic usage. Impacts: This project will use the iPARiHS and SEIPS frameworks to undertake a complete work systems analysis – systematically examining implementation barriers and facilitators to AS interventions. By partnering this project with the AHRQ-funded trial, we will develop practical and applicable implementation recommendations for two core AS interventions (PPA and PAF). These implementation recommendations will fill a critical gap in AS program guidelines and will enhance CDI prevention initiatives across VA.