Assessing the Sustainability of Compliance with Surgical Site Infection Prophylaxis After Discontinuation of Mandatory Active Reporting

背景：SSIS是常见的、可预防的不良手术结果，占相当大的比例 发病率和死亡率。术前应用抗菌药物减少SSI；术后使用抗菌药物 不会减少SSI，但会增加其他术后不良事件。2005年，退伍军人管理局实施了外科手术 护理改善项目(SCIP)，以提高对围手术期质量指标的遵从性，包括 适当使用抗菌药物。SCIP包括一套公开报道的循证抗菌指南 针对高风险手术的合规性指标。这些指标需要大量资源的手动审查，作为一部分 退伍军人事务部的外部同行审查计划(EPRP)。2015年，SCIP实现了持续合规 抗菌药物使用指标超过95%，由于人工审查的高成本，该计划已停用 预期的额外收益微乎其微。本IIR提案以动态可持续发展框架为指导 并审查了SCIP实现的抗菌实践变化是否持续以及它们是如何 扩展到超出原计划范围的外科手术和实践领域。此多个PI提交人 Hillary Mull博士和Westyn Branch博士，医学博士，医学硕士，MMSc在他们之前由退伍军人管理局资助的基础上建立和扩大 合作工作，应用电子算法来衡量抗菌剂的使用并确定不良后果。 意义/影响：提高抗菌药物处方和手术质量是退伍军人管理局的主要目标。在财年 2018年，在退伍军人管理局内，SCIP目标专科(心脏、骨科、 一般/结直肠、妇科和血管)。在这些人中，的门诊率很高，PI发现门诊率很高 指导方针不协调的术后抗菌药物的使用，这导致了实质性的患者伤害。因此， 这项研究对直接临床护理的潜在影响很高。此外，也有一些有限的研究检查 终止旨在支持遵从性的活动计划后，实践会发生什么变化 循证指南。拟议的研究将缩小执行科学研究方面的这一差距。 创新：根据退伍军人管理局的学习健康系统指令，该项目将使用退伍军人管理局的电子设备 健康记录数据，以开发基于PI的算法来识别手术前和术后抗菌药物的使用 之前的工作。这些电子数据挖掘算法捕获结构化和文本注释数据，并表示 与昂贵的人工审查相比，显著的技术进步。这项研究还回答了一些重要的问题 在前线工作人员提供意见的情况下，在一项积极的政策停止后，做法变化的可持续性。 具体目标：1)评估SCIP后抗菌药物预防指南遵从性的可持续性 退休并评估实践变化是否扩展到SCIP排除的程序；2)评估促进者 通过与员工的面谈和实施可持续性的障碍，并将结果与实施相对应 战略；3)制定一份包含评估工具、培训课程和其他要素的实施手册 以支持在未来的HSR&D杂交III试验中扩大和推广循证抗菌实践。 方法：Aim I将采用现有的信息学算法来提取手术前和术后的抗菌药 从每个SCIP手术的临床病历文本和抗菌药订单中使用。以前手动审阅 2005-2015年环境影响评估数据将被用作调整和完善数据挖掘工具的黄金标准。SCIP 可持续性将通过将经过验证的抗菌素遵从性算法应用于2005-2020年的数据来衡量 以及执行中断的时间序列分析。SCIP在专业内的分布将通过回归进行评估 模特们。AIM II将利用与前线工作人员的定性访谈来确定证据可持续的原因- 基于在动态可持续发展框架中使用构造的实践，并将对定性和 量化数据，以确定SCIP的长期影响。AIM III将制定一份实施手册 我们的运营指导委员会由国家和地方退伍军人管理局手术利益相关者组成。 下一步/实施：混合类型III研究中的测试实施手册，以改进实践。

Background: SSIs are common and preventable adverse surgical outcomes that account for substantial morbidity and mortality. Pre-operative antimicrobial administration reduces SSI; post-operative antimicrobials do not reduce SSI but do increase other post-operative adverse events. In 2005, the VA implemented the Surgical Care Improvement Project (SCIP) to increase compliance with peri-operative quality metrics, including appropriate antimicrobial use. SCIP included a set of publicly reported evidenced-based antimicrobial guideline compliance metrics targeting high-risk surgeries. The metrics required resource-intense manual review as part of the VA’s External Peer Review Program (EPRP). In 2015, SCIP achieved sustained compliance with antimicrobial use metrics exceeding 95% and the program was retired due to the high costs of manual review with minimal expected additional benefit. This IIR proposal is guided by the Dynamic Sustainability Framework and examines whether the antimicrobial practice changes achieved by SCIP were sustained and how they spread to surgeries and practice areas beyond the original scope of the program. This multiple PI submission by Dr. Hillary Mull, PhD and Dr. Westyn Branch-Elliman, MD, MMSc builds and expands upon their prior VA-funded collaborative work applying electronic algorithms to measure antimicrobial use and identify adverse outcomes. Significance/Impact: Improving antimicrobial prescribing and surgical quality are major VA goals. In FY 2018, within the VA, there were 190,000 surgeries among SCIP-targeted specialties (cardiac, orthopedic, general/colorectal, gynecology and vascular). Of these, 64% were outpatient, where the PIs found high rates guideline discordant post-operative antimicrobial use, which contribute to substantial patient harms. Thus, the potential impact of the research on direct clinical care is high. In addition, there are limited studies examining what happens to practice change after discontinuation of active programs designed to support compliance with evidence-based guidelines. The proposed study will close this gap in implementation science research. Innovation: In line with the VA’s Learning Health System directive, this project will use the VA’s electronic health record data to develop algorithms to identify pre-and post-operative antimicrobial use based on the PI’s prior work. These electronic data mining algorithms capture structured and text note data and represent a significant technological advancement over costly manual review. This study also answers important questions about the sustainability of practice change after discontinuation of an active policy with input from frontline staff. Specific Aims: 1) Measure sustainability of antimicrobial prophylaxis guideline compliance after SCIP retirement and assess whether practice changes spread to SCIP-excluded procedures; 2) Assess facilitators and barriers to implementation sustainability through staff interviews, and map results to implementation strategies; 3) Develop an implementation playbook with assessment tools, training curricula and other elements to support scale-up and spread of evidence-based antimicrobial practices in a future HSR&D Hybrid III trial. Methodology: Aim I will adapt existing informatics algorithms to extract pre-and post-operative antimicrobial use from clinical note texts and antimicrobial orders for each of the SCIP surgeries. Previously manually reviewed 2005-2015 EPRP data will be used as the gold-standard for adapting and refining the data mining tools. SCIP sustainability will be measured by applying the validated antimicrobial compliance algorithms to 2005-2020 data and performing interrupted time series analyses. SCIP spread within specialties will be assessed with regression models. Aim II will use qualitative interviews with frontline staff to identify reasons for sustainability of evidence- based practice using constructs in the Dynamic Sustainability Framework and will triangulate qualitative and quantitative data to ascertain the long-term impacts of SCIP. Aim III will develop an implementation playbook with input from our Operational Steering Committee comprised of national and local VA surgical stakeholders. Next Steps/Implementation: Test implementation playbook in a Hybrid Type III study to improve practice.