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

背景：艰难梭菌感染（CDI）的发病率和严重程度正在增加， 这类人群感染这种与医疗保健有关的感染的风险较高。尽管在弗吉尼亚州采取了预防措施， 率（根据设施复杂性和患者组合进行调整）在VA站点之间仍然存在很大差异。抗生素 管理（AS）计划已被证明可以降低住院发生的CDI率，因此它们是一个关键因素。 CDI预防方案的组成部分。然而，目前尚不清楚哪些AS策略在以下情况下最有效： 具体降低CDI以及如何有效实施这些AS策略。 具体目标：我们的长期目标是利用实施科学来制定和评估干预措施， 减少医疗相关感染，如CDI。我们的目标是了解上下文和工作系统 作为AS干预措施的一部分的因素及其对临床结局的影响。医疗保健机构 研究和质量（AHRQ）已承诺资助我们的学术附属机构（PI：Safdar）进行一项 随机对照试验：1）测量核心AS干预（处方前授权， PPA）降低CDI率和2）使用系统工程框架来评估上下文， 实施和工作系统因素，有助于临床结果。本次合作评价 该计划将利用AHRQ资金来评估第二个核心项目的临床和实施结果。 以降低CDI为目标的AS干预。在这里，我们将评估一个前瞻性的审计与反馈（PAF） AS干预及其在VA背景下的实施，以便为 设施的特殊需求。我们在这个项目中的目标是： 1：使用综合促进和评价方案活动框架干预措施的执行结果 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）对临床结局的影响-包括CDI率- VA设置。 3：为VA的AS制定和传播旨在减少CDI的可持续建议。 方法：采用导师制实施方法，帮助6个VA住院单元进行优化和实施 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， 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 每个参与单位。我们还将在每个研究中心进行中断的时间序列分析， 干预后数据，以衡量干预对临床结局的影响，如CDI率和 抗生素的使用 影响：本项目将使用iPARiHS和SEIPS框架进行完整的工作系统 分析-系统地审查行政服务干预措施的实施障碍和促进因素。建立伙伴关系 这个项目与AHRQ资助的试验，我们将制定切实可行的实施 两个核心AS干预措施（PPA和PAF）的建议。这些执行建议将 填补了AS计划指南的关键空白，并将加强整个VA的CDI预防计划。

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.