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

评估停止强制主动报告后遵守手术部位感染预防措施的可持续性

• 批准号: 10494063
• 负责人: Westyn Branch-Elliman
• 金额: --
• 依托单位: VA BOSTON HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-10-01 至 2026-09-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10494063
• 关键词: Accounting; Acute Renal Failure with Renal Papillary Necrosis; Address; Adopted; Adoption; Adverse event; Algorithms; Ambulatory Surgical Procedures; Antimicrobial Resistance; Area; Assessment tool; Blood Vessels; Bypass; Cardiac; Caring; Cessation of life; Clinical; Clostridium difficile; Colorectal; Data; Doctor of Philosophy; Documentation; Drops; Educational Curriculum; Electronic Health Record; Electronics; Elements; Evidence based practice; Exclusion; Feedback; Frontline worker; Funding; Future; Goals; Guidelines; Gynecology; Health system; Healthcare; Hybrids; Infection; Informatics; Interruption; Intervention; Interview; Learning; Manuals; Maps; Measurement; Measures; Methodology; Methods; Modeling; Morbidity - disease rate; Operative Surgical Procedures; Orthopedics; Outpatients; Patients; Peer Review; Performance; Perioperative; Pharmacy facility; Policies; Postoperative Period; Prevention Measures; Procedures; Process; Program Reviews; Prophylactic treatment; Provider; Recommendation; Replacement Arthroplasty; Reporting; Research; Resources; Retirement; Sampling; Structure; Surgical Specialties; Surgical Wound Infection; Surgical incisions; Technology; Testing; Text; Time; Time Series Analysis; Training; Translational Research; Work; adverse outcome; antimicrobial; clinical care; contextual factors; cost; data mining; design; effectiveness/implementation study; electronic data; evidence base; evidence based guidelines; healthcare-associated infections; high risk; implementation barriers; implementation science; implementation strategy; improved; informatics tool; innovation; medical specialties; mortality; non-compliance; novel; programs; scale up; structured data; surgery outcome; surgical risk; sustainability framework; tool; voltage

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.

背景：SSI是常见的，可预防的不良外科结果，可说明很大 发病率和死亡率。术前抗菌剂减少SSI；术后抗菌药物 不要减少SSI，而要增加其他术后广告活动。 2005年，VA实施了手术 护理改进项目（SCIP），以提高对围手术质量指标的遵守情况，包括 适当的抗菌使用。 SCIP包括一组公开报告的基于证据的抗菌指南 针对高风险手术的合规指标。指标需要资源 - 手册审查作为一部分 VA的外部同行评审计划（EPRP）。在2015年，SCIP达到了持续的遵守 抗菌使用指标超过95％，由于手动审查的高成本而退休了该计划 最小的预期额外好处。该IIR提案以动态可持续性框架为指导 并检查SCIP实现的抗菌实践变化是否持续以及它们如何 扩展到计划的原始范围之外的手术和练习领域。此多个PI提交 Hillary Mull博士博士和MMSC的Westyn Branch-Elliman博士建立并扩展了其先前的VA资助 使用电子算法来测量抗菌使用并识别广告结果的协作工作。 意义/影响：改善抗菌处方和手术质量是VA的主要目标。在FY中 2018年，在VA内，SCIP靶向专业（心脏，骨科，骨科， 一般/结直肠，妇科和血管）。其中64％是门诊，PI发现高率 指南不一致的术后抗菌抗菌使用，这会导致严重的患者危害。那， 研究对直接临床护理的潜在影响很高。此外，研究有限的研究 在停止旨在支持遵守符合的活动计划之后，练习更改会发生什么 基于证据的准则。拟议的研究将在实施科学研究中缩小这一差距。 创新：根据VA的学习健康系统指令，该项目将使用VA的电子 健康记录数据以开发算法以根据PI的 先前的工作。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 对昂贵的手动审查进行了重大技术进步。这项研究还回答了重要的问题 关于练习的可持续性在停止一项积极政策后使用一线员工的投入。 具体目的：1）衡量SCIP后抗菌预防指南的可持续性 退休和评估实践的变化是否扩散到SCIP排除程序； 2）评估促进者 通过员工面试实施可持续性的障碍，并将结果映射到实施 策略； 3）使用评估工具，培训课程和其他元素开发实施剧本 在未来的HSR＆D Hybrid III试验中，支持基于证据的抗菌实践的扩大和传播。 方法论：目的我将调整现有信息算法以提取术前和术后抗菌剂 每项SCIP手术中的临床注释文本和抗菌阶命令的使用。以前手动审查 2005-2015 EPRP数据将用作适应和完善数据挖掘工具的金标准。 SCIP 可持续性将通过将经过验证的抗微生物合规性算法应用于2005-2020数据来衡量 并执行中断的时间序列分析。 SCIP在专业中的传播将通过回归评估 型号。 AIM II将使用与前线人员进行定性访谈来确定证据可持续性的原因 - 在动态可持续性框架中使用构造的基础实践，并将定性三角进行三角 定量数据以确定SCIP的长期影响。 AIM III将开发一本实施剧本 在我们的运营指导委员会的意见下，由国家和地方弗吉尼亚州外科利益相关者组成。 下一步/实施：在混合III类研究中测试实施剧本，以改善实践。