De-Implementing Testing and Treating of Urine Cultures in Asymptomatic Patients

无症状患者尿培养的取消检测和治疗

• 批准号: 10651593
• 负责人: Marin Leigh Schweizer
• 金额: --
• 依托单位: VA BOSTON HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-12-01 至 2023-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10651593
• 关键词: Address; Adopted; Adverse effects; Adverse event; Advisory Committees; American; Antibiotic Resistance; Antibiotic Therapy; Antibiotics; Area; Bacterial Antibiotic Resistance; Bacteriuria; Caring; Centers for Disease Control and Prevention (U.S.); Cessation of life; Clinical Practice Guideline; Clostridium difficile; Collaborations; Communicable Diseases; Data; Data Analyses; Databases; Deimplementation; Evidence based practice; Fright; Future; Goals; Guidelines; Harm Reduction; Health Status; Healthcare; Healthcare Systems; Homogeneously Staining Region; Hospitals; Infection; Infection prevention; Intervention; Interview; Knowledge; Letters; Life; Link; Methods; Modeling; Operative Surgical Procedures; Organizational Culture; Outcome; Patients; Perioperative Care; Population; Positioning Attribute; Postoperative Period; Prevention; Prevention Research; Process; Provider; Psyche structure; Publications; Random Allocation; Recommendation; Research; Resources; Site; Societies; Stimulus; Surgeon; Surgical Wound Infection; Symptoms; Testing; Time; Time Series Analysis; Translating; Update; Urinary tract infection; Urine; Variant; Veterans; Visit; Work; acute care; antimicrobial; clinical practice; community living; data warehouse; evidence base; implementation framework; implementation measures; implementation science; implementation strategy; implementation tool; improved; improved outcome; innovation; insight; pharmacy benefit; pilot test; programs; provider behavior; screening; social; success; theories; time use; tool

Background: Successful deployment of strategies to reduce unnecessary testing and treatment is a critical component of improving care and minimizing harms. The Choosing Wisely Initiative has highlighted the importance of safely and effectively de-implementing unnecessary testing and treating practices. Positive urine cultures are a major driver of inappropriate antimicrobial use. Asymptomatic patients are often screened and positive urine cultures treated, despite new guidelines from national societies that patients without symptoms of urinary tract infection (UTI) should not have a urine culture performed and should not be treated with antibiotics even if the culture is positive. This inappropriate use of antibiotics can lead to preventable patient harms (e.g., C. difficile infection, antibiotic resistance) without any benefit. This proposal will develop and test a de- implementation strategy for reducing screening and treatment of urine cultures in asymptomatic surgical patients. Specific Aims: Aim 1: Develop a live database of the 15-facility CDC-CREATE Network to identify and to track organizational, provider, and patient level factors associated with preoperative urine testing and ASB treatment. Aim 2: Determine the current context of pre-operative urine testing and treating, and barriers and facilitators to de-implementation, using in-depth interviews at 5 facilities in our CDC-CREATE network. Aim 3: Develop a de-implementation tool and randomly select 5 intervention sites for pilot testing and compare rates of urine testing in 5 randomly selected control sites using time series analysis. Significance: This proposal meets the HSR&D Implementation Science priority area that addresses provider behavior and Secretary Shulkin's Priority 3: Focus Resources More Efficiently. It also addresses the Infectious Diseases Society of America #1 Choosing Wisely recommendation which says, “Don't treat asymptomatic bacteriuria with antibiotics.” The impact on Veteran's healthcare will be to focus resources towards evidence based practices that are associated with benefits (surgical prevention checklist) and away from potentially harmful practices (urine testing and treatment in asymptomatic patients). This innovative approach will translate new guidelines - to do less - into action using a theory based multi-pronged intervention. Methods: We will partner with the De-implementation Quality Enhancement Research Initiative (QUERI) and adapt their conceptual framework to achieve the proposal objectives. In addition, we will utilize our existing partnership with the CDC-CREATE network of sites to evaluate the context, facilitators and barriers to stopping urine culture practices in asymptomatic surgical patients and to pilot test a de-implementation strategy. We will use a mixed-methods approach, including analyses of data from the national VA databases (e.g. Corporate Data Warehouse), qualitative interviews, and piloting of a de-implementation strategy with a goal of wider dissemination in future work. We anticipate that the de-implementation strategy created and tested in this study will reduce urine testing and treatment in asymptomatic surgical patients. Implications and Next Steps: Our study will provide important insights into patient, provider, and hospital level factors, as well as organizational culture and broader external context (e.g., professional, social) associated with unnecessary urine testing and antibiotic treatment of surgical patients. Our study will develop a strategy to provide reliable, relevant data to the providers so they can do a critical assessment of the evidence against urine testing (unlearning) and adopt a substitute process to optimize the success of our de- implementation goal. Our next steps will be to test the intervention in a wider array of facilities and to work with the Antimicrobial Stewardship Task Force to disseminate our findings to VA antimicrobial stewardship teams nationwide. Our future goals are to disseminate the strategy nationally and to expand it to other patient settings, such as acute care and community living centers.

背景：成功部署战略以减少不必要的检测和治疗是一个关键 改善护理和最大限度地减少伤害的组成部分。明智选择倡议强调了 安全有效地取消不必要的检测和治疗做法的重要性。阳性尿液 文化是不适当使用抗菌剂的主要驱动因素。无症状患者经常接受筛查， 尽管国家协会的新指南规定，没有症状的患者， 尿路感染（UTI）不应进行尿培养，也不应使用抗生素治疗 即使文化是积极的。抗生素的这种不当使用可能导致可预防的患者伤害（例如， C.艰难梭菌感染，抗生素耐药性），没有任何好处。该计划将开发和测试一个... 减少无症状外科手术患者尿培养筛查和治疗实施策略 患者 具体目标：目标1：建立一个由15个设施组成的疾病预防控制中心-创建网络的实时数据库， 跟踪与术前尿检和ASB相关的组织、提供者和患者水平因素 治疗目的2：确定术前尿液检测和治疗的当前背景，以及障碍和 促进者去实现，在我们的CDC-CREATE网络中的5个设施进行深入访谈。目标3： 开发一个取消执行工具，并随机选择5个干预地点进行试点测试，并比较比率 使用时间序列分析在5个随机选择的对照点进行尿液检测。 重要性：本提案符合HSR&D实施科学优先领域的要求， 舒尔金部长的优先事项3：更有效地集中资源。它还解决了传染性 美国疾病协会#1明智地选择建议，其中说，“不要治疗无症状 细菌尿症和抗生素。”对退伍军人医疗保健的影响将是将资源集中在证据上 基于与受益相关的实践（手术预防清单）， 有害做法（尿检和无症状患者的治疗）。这种创新的方法将 利用基于理论的多管齐下的干预措施，将新的指导方针-少做事-转化为行动。 方法：我们将与反实施质量提高研究倡议（QUERI）合作， 调整其概念框架，以实现提案目标。此外，我们将利用现有的 与CDC-CREATE网站网络建立伙伴关系，以评估停止的背景、促进因素和障碍 无症状手术患者的尿培养实践，并对取消实施策略进行试点测试。我们将 使用混合方法，包括分析来自国家VA数据库的数据（例如： 数据仓库），定性访谈，并试行一项取消执行战略，目标是更广泛地 在今后的工作中传播。我们预计，在这项研究中创建和测试的去实现战略 将减少无症状手术患者的尿检和治疗。 影响和下一步：我们的研究将为患者，提供者和医院提供重要的见解 水平因素，以及组织文化和更广泛的外部环境（例如，专业、社会） 与不必要的尿检和外科病人的抗生素治疗有关。我们的研究将开发一种 向提供者提供可靠、相关数据的策略，以便他们对证据进行关键评估 反对尿检（忘却），并采取替代过程，以优化我们的去- 实施目标。我们的下一步将是在更广泛的设施中测试干预措施， 抗菌药物管理工作组将我们的发现传播给退伍军人管理局抗菌药物管理团队 全国范围我们未来的目标是在全国范围内传播该战略，并将其推广到其他患者。 环境，如急性护理和社区生活中心。